GUIDES  FOR  HISTORY  TAKING 
AND   CLINICAL  EXAMINATION 

OF 

PSYCHIATRIC  CASES 


EDITED  BY 

GEORGE  H.  KIRBY,  M.  D. 
Director,  New  York  State  Psychiatric  Institute 


PUBLISHED  BY 

THE  NEW  YORK  STATE  HOSPITAL  COMMISSION 
ALBANY,  N.  Y. 


UT1CA.  N.  Y. 

STATE  HOSPITALS  PRESS 
1921 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 


DR.  ROY  VAN  WART 


Biomedieal 
Library 


CONTENTS 


PAQ» 

PREFACE  5 

I .     THE  USE  OF  GUIDES  IN  CLINICAL  PSYCHIATRY  ...  6 

II .     THE  ANAMNESIS  GUIDE 9 

III .     THE  PERSONALITY  21 

IV .     PHYSICAL  EXAMINATION  GUIDE 29 

V .     BODY  DEVELOPMENT  AND  ENDOCRINE  GLANDS  ...  43 

VI .     MENTAL  EXAMINATION  57 

VII .     FURTHER  PSYCHOLOGICAL  ANALYSIS 78 

VIII.     EXAMINATION  OF  NON-COOPERATIVE  OR  STUPOR- 

ous  PATIENTS  .  81 


635441 


PREFACE 

Over  fifteen  years  ago  Dr.  Adolf  Meyer,  then  Director 
of  the  Psychiatric  Institute,  prepared  a  set  of  clinical  guides 
or  outlines  for  use  in  the  New  York  State  Hospitals.  These 
were  furnished  the  physicians  in  typewritten  form.  Their 
practical  value  was  quickly  recognized  with  the  result  that 
they  were  adopted  as  the  standard  method  of  clinical  study, 
not  only  in  the  New  York  State  Hospitals,  but  in  many  other 
institutions  throughout  the  country.  A  number  of  changes 
and  additions  to  the  guides  have  been  made  with  the  pas- 
sage of  time  and  the  advance  of  psychiatric  knowledge,  but 
there  has  been  no  departure  from  the  general  plan  origin- 
ally formulated  by  Dr.  Meyer  for  history  taking  and  clinical 
examination  of  mental  cases. 

There  has  long  been  a  demand  that  the  guides  be  made 
available  for  use  in  permanent  printed  form.  The  decision 
of  the  State  Hospital  Commission  to  publish  the  guides 
gave  the  editor  an  opportunity  to  revise  and  amplify  them 
in  several  directions  and  to  add  considerable  new  material 
which  has  been  accumulated  as  the  result  of  the  experience 
of  recent  years. 

The  guide  for  the  study  of  the  personality  make-up  is 
based  on  the  well  known  work  of  Hoch  and  Amsden  and  fol- 
lows in  a  general  way  the  outline  prepared  by  Dr.  Hoch 
for  use  in  the  State  Hospitals  while  he  was  Director  of  the 
Institute. 

Dr.  Clarence  0.  Cheney,  Assistant  Director  of  the  Insti- 
tute helped  materially  in  the  revision,  and  the  guide  for 
the  study  of  body  development  and  the  endocrine  glands 
is  almost  entirely  his  work.  Dr.  Charles  E.  Gibbs  of  the 
Institute  Staff  assisted  in  revising  the  anamesis  guide. 

From  various  physicians  in  the  New  York  State  service 
helpful  suggestions  have  been  received.  The  Editor  wishes 
to  acknowledge  particularly  the  assistance  rendered  by  Dr. 
George  W.  Mills,  Clinical  Director  of  the  Central  Islip 
State  Hospital,  and  Dr.  Mortimer  W.  Raynor,  Clinical 
Director  of  the  Manhattan  State  Hospital. 

October  1,  1921.  G.  H.  K. 


THE  USE  OF  GUIDES  IN  CLINICAL  PSYCHIATRY 

The  necessity  of  following  some  kind  of  a  plan  or  method 
of  case-study  in  psychiatric  work  is  universally  recognized. 
Physicians  taking  up  psychiatry  should,  therefore,  first 
of  all,  try  to  perfect  themselves  in  the  art  of  history  taking 
and  strive  to  develop  a  good  technique  for  the  examination 
of  mental  patients.  Facility  and  skill  in  these  directions 
will*  be  acquired  slowly  and  only  after  painstaking  effort. 
Method  and  technique  are  certainly  just  as  important  in 
psychiatry  as  in  any  branch  of  internal  medicine  or  clinical 
diagnosis. 

Owing  to  the  variety  and  complexity  of  the  situations 
dealt  with  in  the  investigation  of  life  histories  and  the 
difficulties  encountered  in  the  examination  of  many  types 
of  mental  disorder,  the  physician  who  approaches  a  case 
without  a  definite  plan  in  mind  is  certain  to  overlook  im- 
portant facts  or  permit  the  patient  to  lead  too  much  in  the 
examination,  often  with  the  result  that  the  time  is  not  spent 
to  the  best  advantage. 

One  of  the  chief  obstacles  in  developing  a  satisfactory 
scheme  has  lain  in  the  difficulty  of  devising  guides  that 
would  meet  the  requirements  of  the  widely  differing  types 
of  cases  without  at  the  same  time  becoming  too  cumbersome 
and  involved  for  practical  clinical  application.  Further- 
more, the  kind  of  guidance  needed  by  one  beginning  psychi- 
atric work  is  quite  different  from  that  required  by  an 
experienced  clinician.  One  unfamiliar  with  the  guides 
presented  in  the  following  pages  will  perhaps  at  first  feel 
that  they  are  too  elaborate  and  go  too  much  into  detail; 
especially  is  this  likely  to  be  the  reaction  of  one  who  must 
examine  fairly  rapidly  a  large  number  of  cases,  a  situation 
which,  unfortunately,  often  confronts  physicians  in  state 
hospitals.  The  fact  that  work  must  sometimes  be  done 


under  conditions  unfavorable  for  the  best  and  most  satis- 
factory results  furnishes  no  valid  reason  for  objection  to  a 
method  which  aims  at  a  higher  level  of  thoroughness  and 
completeness. 

The  guides  present  in  some  detail  the  various  topics 
which  it  is  essential  to  keep  in  mind  if  cases  are  to  be  care- 
fully and  adequately  studied.  It  is  not  expected  that  one 
would,  even  under  ideal  conditions,  undertake  to  follow  out 
in  every  case  every  line  of  inquiry  suggested  in  the  various 
guides.  The  guides  contain  a  good  deal  of  information  and 
various  tests  which  should  be  available  when  needed.  One 's 
experience  and  judgment  must  decide  how  far  it  is  desirable 
or  necessary  to  push  the  examination  in  this  or  that  direc- 
tion. Thorough  familiarity  with  the  guides  and  the  general 
plan  of  study  outlined  will  give  the  physician  a  solid  foun- 
dation on  which  to  develop  good  psychiatric  technique  and 
clinical  skill,  will  make  the  daily  work  more  interesting  and 
valuable,  and  will  qualify  him  to  make  special  clinical 
studies  and  investigations  as  opportunities  arise. 


8 


THE  ANAMNESIS  GUIDE 

(Synopsis) 

INTRODUCTION 

1.  INFORMANT 

2.  FAMILY  HISTORY 

3.  PERSONAL  HISTORY 

I.  Birth  and  Early  Development 

II.  Intellectual  and  Social  Development 

HI.  Sexual  Development  and  Function 

TV .  Diseases  and  Injuries 

V .  Occupation 

VI.  Alcohol  and  Other  Toxic  Influences 

VII.  Previous  Attacks  of  Mental  Disorder 

VIII.  Etiologic  Factors  and  Precipitating  Causes 

4.  ONSET  AND  SYMPTOMS  OF  THE  PSYCHOSIS 


II 

THE  ANAMNESIS  GUIDE 

Introduction.  In  the  study  of  mental  cases  nothing  is 
more  important  than  a  good  account  of  the  previous  history 
of  the  patient,  the  physical  and  mental  development,  and 
the  manner  in  which  the  psychosis  began.  Without  this 
information  it  •will  be  quite  impossible  in  many  cases  to 
understand  the  nature  of  the  disorder  or  to  make  a  satis- 
factory diagnostic  grouping  of  the  cases.  It  is  therefore 
essential  to  devote  as  much  time  and  care  as  possible  to  the 
obtaining  of  full  and  reliable  statements  from  visitors.  It 
requires  time  and  experience  to  become  proficient  in  this 
aspect  of  psychiatric  work. 

In  mental  cases  the  practice  should  be  to  try  always  to 
get  the  anamnesis  from  relatives  or  friends,  as  in  many 
instances  one  cannot  depend  on  the  patient  for  the  previous 
history  as  is  usually  done  in  general  medical  cases.  A 
number  of  interviews  with  the  same  informant,  or  with 
different  members  of  the  family,  or  friends,  will  in  most 
cases  he  necessary  in  order  to  obtain  a  correct  estimate 
of  the  family  stock  and  traits  and  to  get  a  satisfactory  ac- 
count of  the  patient's  life  and  mental  breakdown.  It  is 
particularly  difficult  to  obtain  a  good  anamnesis  by  means 
of  correspondence  or  through  attendants,  although  the  latter 
often  do  very  well  if  an  effort  is  made  to  train  them  by  some 
systematic  instruction  in  history  taking  and  in  the  use  of 
suitable  guides  or  forms.  Trained  psychiatric  social  work- 
ers may  often  be  of  great  assistance  in  getting  histories  and 
the  physician  should  not  neglect  to  utilize  to  the  fullest 
extent  the  services  of  the  social  worker  in  securing  the 
desired  information. 

In  the  following  guide  various  important  lines  of  inquiry 
are  taken  up  under  certain  general  headings.  This  is  done 
for  purposes  of  convenience  and  systematic  approach,  but 


10 

the  sequence  suggested  need  not  in  all  cases  be  followed. 
It  must  also  be  constantly  borne  in  mind  that  a  psychiatric 
history  portrays  growth,  development  and  change  —  a 
stream  of  events  and  the  reaction  to  them,  so  that  an  ac- 
count of  the  individual  as  to  tendencies  or  health  at  one 
period  may  be  quite  different  from  that  of  another  time 
of  life.  There  are  some  advantages  in  dividing  up  the 
descriptions  roughly  into  the  periods  of  infancy  and  child- 
hood, puberty,  adult  life,  involution,  senescence  —  all  of 
which  have  special  features,  physical  and  mental,  that  are 
of  great  psychiatric  importance. 

Before  the  anamnesis  is  considered  complete,  all  of  the 
topics  mentioned  should  be  covered  by  an  appropriate  in- 
quiry. But  common  sense  and  judgment  must  be  used  in 
deciding  just  what  amount  of  detailed  investigation  the 
different  topics  call  for.  We  learn  by  experience  where  to 
place  the  emphasis  and  in  what  direction  to  press  our  in- 
quiries. The  anamnesis  of  a  case  of  senile  psychosis  will 
be  taken  with  a  different  object  in  view  than  that  pursued 
in  a  case  of  dementia  prsecox. 

The  use  of  short  summarizing  headings  for  the  different 
paragraphs  or  topics  is  advised,  as  these  render  it  easy  to 
get  rapidly  the  salient  facts  from  a  case  history.  The 
headings  should,  however,  be  brief  and  concise  and  not 
simply  a  somewhat  shorter  statement  of  what  is  to  follow 
in  the  paragraph. 

In  cases  where  there  are  no  relatives  or  visitors  and  the 
patient  must  give  the'  previous  history,  it  is  advised  that 
this  be  recorded  in  the  usual  form  of  an  anamnesis  and  be 
placed,  as  is  customary,  in  the  front  part  of  the  case  record 
rather  than  incorporated  in  that  division  of  the  mental 
status  dealing  with  memory  tests  and  the  patient's  ability 
to  give  personal  data.  In  some  cases  it  will,  of  course,  not 
be  possible  to  take  an  anamnesis  from  the  patient  until  the 
more  disturbed  phase  of  the  psychosis  has  subsided  or 
even  until  convalescence  has  set  in.  Case  histories  often 
lose  a  great  deal  of  their  value  because  no  anamnesis  was 


11 

obtained  from  the  patient  before  discharge  or  from  the 
visitor  who  came  to  take  the  patient  home. 

It  is  suggested  that  the  physician  always  have  the  guide 
at  hand  when  the  visitors  are  interviewed.  In  addition  the 
physician  should  have  before  him  the  following : 

1.  The  commitment  paper  or  a  typewritten  copy  of  it 
if  the  patient  is  a  committed  one.    It  is  important  to  go 
over  the  statements  of  the  relatives  and  the  patient  con- 
tained in  the  paper.    Very  often  relatives  deny  statements 
made  to  the  committing  physicians  or  give  quite  a  different 
account  of  happenings  preceding  the  patient's  admission 
than  that  recorded  in  the  commitment  paper. 

2.  The  statistical  data  sheet  (New  York  State  Hospital 
Form  22-Medical).    This  should  be  filled  in  as  far  as  pos- 
sible at  the  time  the  anamnesis  is  taken  because  many  of 
the  items  require  special  inquiry  if  accurate  statistical  data 
are  to  be  obtained.     It  is  also  important  to  complete  as 
much  of  the  data  sheet  at  this  first  interview  as  possible 
because  of  certain  information  called  for  in  death  certifi- 
cates, in  questions  of  legal  residence,  in  deportation  pro- 
ceedings, etc. 


12 


THE  ANAMNESIS 

Taken  by  Date 

INFORMANT  : 

1.  Name 

2.  Address 

3.  Relationship  to  patient 

4.  Intelligence  and  reliability 

Record  any  mental  or  physical  abnormality  observed  in 
the  informant  and  other  relatives  seen.  Subsequent  family 
history  and  observations  made  on  relatives  may  be  recorded 
as  an  addition  to  the  family  history  and  inserted  in  the 
case  record. 

FAMILY  HISTORY: 

The  family  history  furnishes  evidence  as  to  the  hereditary 
factor  as  well  as  the  environmental  influences.  In  addition 
to  a  history  of  definite  psychosis  or  nervous  disease,  it  is 
desirable  to  secure  evidence  of  the  various  less  direct  and 
specific  factors  which  throw  light  on  the  social  reactions 
and  intellectual  development  as  well  as  the  physical  make- 
up and  defects  of  the  different  members  of  the  family. 
Deviations  from  normal  may  not  be  manifest  in  the  same 
way  in  each  generation.  A  member  of  one  generation  may 
show  evidence  of  endocrine  disturbance  in  the  form  of 
goiter,  while  a  member  of  the  previous  generation  may  have 
displayed  the  disturbed  metabolism  of  diabetes. 

It  is  not  sufficient  to  ask  simply  the  general  question: 
has  any  member  of  the  family  been  insane  or  nervous?  A 
great  many  persons  will  answer  in  the  negative,  whereas, 
a  detailed  inquiry  will  often  bring  out  a  number  of  in- 
stances of  nervous  or  mental  troubles.  In  a  similar  way 
questions  regarding  physical  defects  and  diseases  in  the 
ancestors  must  be  as  specific  as  possible.  All  questions 
should  be  put  in  non-technical  terms,  and  judgment  and 


13 

discrimination  must  be  used  in  accepting  as  a  settled  fact 
diagnoses  or  causes  of  death  as  given  by  the  informant. 
A  descriptive  statement  as  a  rule  is  much  preferable  to  a 
one-word  diagnosis. 

In  order  to  cover  the  ground  satisfactorily  specific  in- 
quiry should  be  made  concerning  each  member  of  the  family 
indicated  below  and  the  data  recorded  in  the  sequence 
given.  If  the  informant  has  no  knowledge  regarding  any 
individual  of  the  given  generations,  it  should  invariably 
be  mentioned  in  order  that  in  our  statistical  studies  we 
may  be  able  to  put  together  the  cases  about  which  we  have 
the  facts  and  exclude  those  about  which  we  have  no  infor- 
mation. It  is  not  permissible  merely  to  say  that  the  family 
history  is  negative :  this  rarely  if  ever  can  be  proven  to  be 
true  especially  if  we  have  complete  and  reliable  data  cover- 
ing several  generations.  One  may,  therefore,  usually  make 
a  statement  that  the  history  is  negative  only  in  reference 
to  a  particular  generation  or  branch. 

The  direct  line  includes 

1.  Paternal  grandfather 

2.  Paternal  grandmother 

3.  Maternal  grandfather 

4.  Maternal  grandmother 

5.  Father 

6.  Mother 

7.  Children  in  family,   siblings  or  brothers  and  sisters  of 

patient.    Record  in  order  of  birth,  including  still-births 
and  those  dead. 

8.  Children  of  patient,  give  in  order  of  birth. 

The  collateral  line  includes 
Uncles,  aunts,  and  cousins. 

The  aim  should  be  to  obtain  as  complete  information  as 
possible  regarding  all  members  of  the  direct  line  and  to 
gather  as  many  facts  as  is  feasible  regarding  the  collateral 
lines.  With  this  object  in  view,  the  history  of  each  individ- 
ual of  the  different  generations,  as  above  indicated,  must 


14 

be  systematically  recorded.    The  data  may  be  conveniently 
arranged  and  classified  as  follows :  ' 

1.  Name,  relationship  to  the  patient,  living  or  dead,  age,  cause 

of  death,  occupation 

2.  Mental  disease:  psychosis  or  suicide 

3.  Mental  deficiency:  idiot,  imbecile,  moron 

4.  Nervous  disease : 

(a)  Organic:  brain  tumor,  cerebral  arteriosclerosis,  mul- 

tiple sclerosis,  paralysis  agitans,  Huntington  's  chorea, 
muscular  atrophies,  etc. 

(b)  Functional:    psychoneuroses,   ''nervous  prostration," 

acute  chorea,  migraine,  epilepsy,  etc. 

5.  Psychopathic   personality:   eccentricity,   seclusiveness,   emo- 

tional instability  (excitable,  depressive,  cyclothymic), 
irritability,  stubbornness,  suspiciousness,  suicidal  impulses, 
nomadism,  criminality,  sexual  perversions,  etc. 

6.  Alcoholism,  drug  addiction,  or  exposure  to  other  toxic  exog- 

enous agents 

7.  Physical  defects  and  diseases : 

(a)  General 

Gastro-intestinal 

Cardio-vascular,   often  referred   to   as   "apoplexy", 

"stroke"  or  paralysis 
Renal  disease 
Cancer 
Gout 
Asthma 

(b)  Infections 

Tuberculosis 
Syphilis 

Other  infections:  typhoid,  rheumatism,   pneumonia, 
etc. 

(c)  Endocrine  and  metabolism  disorders 

Giantism,  dwarfism 
Obesity,  abnormal  leanness 
Thyroid  disease,  diabetes 


15 

(d)  Defects  of  development  and  "stigmata  of  degenera- 
tion", deaf -mutism,  albinism,  congenital  deform- 
ities, unusually  large  or  small  hands,  feet,  or  head. 

PERSONAL  HISTORY  : 

I.  Birth  and  early  development 

Present  age  Date  of  birth 

Place  of  birth 

Mother's  condition  during  pregnancy 

Character  of  labor         Unusual  incidents  or  complications 

General  health  in  infancy  and  childhood :    Robust,  delicate 

or  sickly 
Infantile  and  childhood  diseases  Age,  severity  and 

complications        Injuries        Spasms        Convulsions 
Bed-wetting  When  stopped 

Talked  and  walked  at  what  age 
Disposition  as  a  child        Docile,  happy,  cranky,  peevish, 

fretful          Tantrums  or  fits  of  temper 
Night  terrors,  fears,  frights,  chorea 
Was  growth  regular,  slow,  or  rapid. 
Any  special  period  of  rapid  growth 
Thin  or  fat 

Nose  bleeding:    Periodicity 
Headaches:     Character,  location,  periodicity 

II.  Intellectual  and  Social  Development 

Infancy  and  childhood :  bright,  dull,  or  average 

School  history :  years  at  school,  progress,  interest,  behavior. 

age  and  grade  at  which  stopped        Play  activities  and 

attitude  to  playmates 
Delinquency:     truancy,  waywardness,  tramp-life,   police 

record 

Adult  intellectual  level:  well  informed  or  ignorant 
General  range  of  interests  and  social  activities 
Religious  affiliations:  devout  or  indifferent 

III.  Sexual  Development  and  Function 

1 .     Physiologic 

Males.  Age  at  puberty  or  when  first  shaved,  or  when 
voice  changed  Masturbation,  when  begun, 
how  long  continued  Frequency 


16 

Sexual  activity :  relations  with  women,  char- 
acter and  frequency  Single  or  married, 
age  at  marriage,  number  of  children  Anti- 
conceptual  measures  Any  change  in  sexual 
power  Impotency  How  long  Date  of 
last  intercourse 

Females.    Menstrual  history      Age  at  onset 

Regularity        Amount  and  duration 
Preceding  symptoms 
Associated  symptoms 
Post-menstrual  symptoms 
Headaches      Character  and  duration 
,;  Masturbation       When  begun       How  long 

continued      Frequency 
Single  or  married        Age  at  marriage 
Pregnancies        Abortions 
Number  of  children  Anti-conceptual 

measures 

Menopause :    Age  and  accompanying  symp- 
toms 
2.    Psycho-sexual 

Unusual  childhood  interests  or  curiosity 
Adolescent  interests.     Abnormal  love  attachments  or 

perversions 

Family  situation:     strong  attachments  or  antagon- 
isms to  either  parent,  or  to  other  members  of  the 
family    Special  dependence  or  reluctance  to  leave 
home    Attitude  toward  family  determined  by  any 
special  occurrences. 
Love  affairs  and  disappointments 
Sexual  irregularities,  seduction  or  prostitution 
Reasons  for  marriage  or  for  single  life 
Treatment  of  partner — abuse,  separation,  divorce 

IV.    Diseases  and  Injuries 

1.  General.  What  sickness  has  patient  had  since  child- 
hood Were  any  mental  symptoms  associated 
Gastro-intestinal,  cardio-vascular,  renal,  or  urinary 
disorders  Gout  Convulsions,  fainting  attacks, 
migraine 


17 

2.  Infections 

Tuberculosis.  Evidence  of  active  infection,  loss  of 
weight,  cough,  hemoptysis,  weakness,  hematuria, 
pleurisy,  adenitis,  night  sweats,  etc. 

Syphilis.  Sore,  eruptions,  etc.  Age  when  acquired, 
treatment,  symptoms  of  involvement  of  nervous 
system 

Focal  and  other  infections.  Tonsilitis,  ulcerated 
teeth,  otitis  and  sinusitis,  rheumatism,  heart  disease, 
acute  chorea,  gonorrhoea,  prostatitis,  etc.  Measles, 
diphtheria,  typhoid,  pneumonia,  influenza 

3.  Symptoms    suggestive    of    endocrine    and   vegetative 

nervous  system  disturbances 

The  information  already  obtained  regarding  the 
family  and  personal  history  may  have  indicated 
the  presence  of  some  endocrine  or  vegetative  nervous 
system  disturbance.  In  any  case  the  following 
points  should  be  covered  in  the  inquiry  for  endoc- 
rine disorders: 

Abnormal  desire  for  sweets,  fats,  fluids 

Regularity,  degree  of  such  desire,  and  bad  symp- 
toms following 

Increased  urination — day  or  night 

Diabetic  symptoms 

Investigation  of  disorders  referable  to  the  vegetative 
nervous  system  should  include  the  following : 
Sensations  of  heat  or  cold 
Hay  fever,  asthma,  eczema,  urticaria 
Exhaustion  or  lassitude 
Chills  and  goose  flesh 

V.  Occupation 

Kinds  of  work  undertaken,  ambition,  efficiency,  wages,  etc. 
Length  of  time  in  different  positions,  reasons  for  changes,  etc. 

VI.  Alcohol  and  Other  Toxic  Influences 

Intemperate,  moderate,  or  total  abstainer.  If  intemperate, 
age  at  which  drinking  began,  apparent  cause  of  excesses,  kind 
of  beverage  consumed  and  approximate  amounts.  Periodic 
or  steady  drinker.  Usual  reaction  to  alcohol. 


18 

If  intemperate,  inquire  about  attacks  of  neuritis,  delirium, 
hallucinatory  episodes,  suspicions,  ideas  of  jealousy. 

Other  Toxic  Influences.  Drug  habits,  occupational  poisons, 
lead,  arsenic,  phosphorus,  mercury,  etc. 

Illuminating  gas  poisoning,  nicotine,  intoxication,  food 
toxicoses. 

VII.  Previous  Attacks  of  Mental  Disorder 

Get  dates,  places  where  treated,  apparent  cause,  duration 
of  attacks  and  general  character  of  symptoms. 
Associated  physical  diseases. 

VIII.  Etiologic  Factors  and  Precipitating  Causes  of  Present 

Psychosis 

Often  the  psychosis  appears  to  have  gradually  developed 
in  connection  with  causes,  physical  or  mental,  or  both,  oper- 
ating over  a  comparatively  long  period.  In  some  cases  the 
causes  may  be  indefinite  or  not  easily  elicited,  but  careful 
inquiry  should  be  made  in  such  instances  for  possible  etiologic 
factors  and  an  evaluation  made  of  them. 

In  other  cases,  however,  the  mental  break-down  seems  to 
have  come  on  more  or  less  abruptly  as  if  precipitated  by  some 
special  occurrence  or  situation.  Especially  to  be  inquired 
about  are: 

Mental  Causes  of  an  emotional  nature  such  as  love  affairs, 
sexual  episodes,  disappointments,  reverses,  quarrels,  separa- 
tions, deaths  in  the  family,  childbirth,  etc. 

Physical  Causes  such  as  acute  or  chronic  illness,  infection, 
childbirth,  exhaustion,  injury,  operation,  etc. 

ONSET  AND  SYMPTOMS  OF  THE  PSYCHOSIS 

Take  as  far  as  possible  a  spontaneous  account  beginning  with 
the  date  when  the  first  symptoms  were  noticed  in  the  patient. 
In  this  connection  particular  attention  should  be  given  to 
changes  in  behavior,  in  mood,  in  manner  of  speech,  in  attitude 
toward  others  and  toward  work. 

The  early  symptoms  may  be  physical.  In  an  organic  brain 
disease  we  may  find  among  the  first  symptoms  an  eye-muscle 
palsy,  a  fainting  spell,  headache,  pains,  etc;  in  constitutional 
mental  disorders  the  onset  may  be  associated  with  prominent 
physical  complaints,  e.  g.,  gastro-intestinal  symptoms,  fussing 
about  health,  hypochondriasis,  etc. 


19 

Inquiry  should  be  made  regarding  the  appearance  of  sus- 
picions, unusual  interests,  peculiar  ideas  and  delusions. 

Hallucinations  in  various  fields  and  the  reaction  to  them. 

Obtain  as  much  as  possible  regarding  the  trend  of 
patient's  ideas,  topics  of  conversation  and  content  of  hallucin- 
ations. What  did  the  voices  say?  What  was  seen  in  visions? 

Forgetfulness,  impairment  of  memory,  loss  of  orientation, 
clouding  of  sensorium,  delirium. 

Always  inquire  regarding  suicidal  inclinations  or  attempts, 
threats  of  violence,  assaults  or  homicidal  tendencies. 

Compare  informant's  statement  with  those  given  in  com- 
mitment certificate. 

What  treatment  was  given  at  home?  Name  of  physician  in 
attendance. 

Date  on  which  patient  was  taken  from  home  to  hospital. 
By  what  means  taken,  by  whom  accompanied,  and  what  was 
the  patient's  reaction  to  the  removal? 


20 


THE  PERSONALITY 

(Synopsis) 
INTRODUCTION 

I.     GENERAL,  INTELLIGENCE,  KNOWLEDGE  AND 
JUDGMENT 

II .  OUTPUT  OF  ENERGY 

III.  GENERAL  ATTITUDE  TOWARD  ENVIRONMENT 

VI .  ATTITUDE  TOWARD  SELF  :  INNER  MENTAL  LIFE 

V .  ATTITUDE  TOWARD  BEAUTY 

VI.  MOOD:    EMOTIONAL  REACTIONS 

VII.  SEXUAL  INSTINCTS 

VIII.  FEELING  OF  INFERIORITY 

IX.  SUMMARY  OF  PERSONALITY  TRAITS 


in 

THE  PERSONALITY 

Introduction.  In  taking  the  general  anamnesis,  ques- 
tions of  mental  make-up  and  temperamental  reactions  will 
naturally  be  touched  upon  to  some  extent.  The  relation  of 
psychosis  to  personality  is,  however,  such  an  extremely  im- 
portant one  that  it  becomes  necessary  to  make  a  special 
inquiry  into  the  habitual  or  preferred  mental  reactions 
which  characterized  the  individual  prior  to  the  time  of  the 
appearance  of  definite  signs  of  a  mental  breakdown. 

The  various  traits  which  together  form  the  ensemble 
which  we  call  the  personality  are  of  complex  origin,  being 
determined  by  instinctive  reactions,  early  experiences  and 
training  and  a  gradual  development  of  mental  habits,  in- 
terests and  attitudes.  It  is  of  great  importance  to 
know  something  about  an  individual's  customary  way 
of  meeting  various  situations,  e.  g.,  whether  the  prefer- 
ence is  for  a  square  facing  of  difficulties  or  for  evasion, 
substitution  or  some  sort  of  escape.  It  is  now  well  estab- 
lished that  the  preferred  or  habitual  reactions  peculiar  to 
a  person  tend  to  appear  in  accentuated  form  in  the  psychosis 
which  thus  derives  many  of  its  characteristics  directly  from 
the  constitutional  background ;  from  the  standpoint  of  path- 
ogenesis  there  is  reason  to  believe  that  preferred  reactions 
often  actually  serve  to  guide  an  individual  into  a  psychosis. 
We  should,  therefore,  strive  to  obtain  as  precise  and  ac- 
curate descriptions  as  possible  of  mental  traits  or  tendencies 
which  influence  the  mental  balance  for  better  or  for  worse. 

It  is  difficult  to  classify  the  various  traits  which  we  wish 
to  study  and  it  takes  time  and  patience  to  collect  data  on 
which  to  form  an  opinion  of  the  habitual  reactions  of  an 
individual  or  to  fairly  gauge  the  capacity  for  adaptation 
and  adjustment.  In  the  following  guide  special  attention 
is  devoted  to  those  traits  which  psychiatric  experience  has 
shown  to  be  worth  knowing  about  and  which,  when 


22 

summed  up,  give  for  practical  purposes  a  fair  description 
of  the  personality. 

In  the  guide  the  traits  to  be  studied  are  arranged  in  eight 
groups.  The  divisions  are  more  or  less  arbitrary  and  the 
questions  naturally  overlap  to  some  extent ;  no  attempt  was 
made  to  make  the  inquiries  fit  into  any  rigid  system  of 
psychological  categories.  The  questionnaire  is  based 
largely  on  the  study  of  Hoch  and  Amsden  to  which  refer- 
ence may  be  profitably  made.  ( See  State  Hospitals  Bulle- 
tin, Nov.  1913.) 

In  getting  the  data  it  is  of  course  essential  to  interview 
the  relatives  and  friends  best  qualified  by  personal  asso- 
ciation with  the  patient  to  give  the  information  desired. 
During  the  interviews  technical  terms  should  be  carefully 
avoided;  the  informant  should  describe  without  being  led 
by  suggestive  questions.  Concrete  illustrations  of  the  way 
the  patient  acted  at  certain  times  or  responded  to  certain 
situations,  are  of  especial  value  and  should  be,  whenever 
possible,  incorporated  in  the  study.  One  should  note 
whether  the  personal  traits  studied  have  undergone  changes 
in  the  course  of  life  from  childhood  to  puberty  or  in  later 
years  and  the  involution  period.  As  emphasized  by  Amsden 
the  personality  should  not  be  regarded  as  something  static 
or  fixed ;  we  really  have  to  do  with  a  continuous  stream  of 
developing  traits  and  characteristics  which  vary  at  differ- 
ent times  and  in  different  periods  of  life.  At  the  same 
time  one  may  observe  deeply-seated  or  persistent  tenden- 
cies which  make  for  good  or  bad  reactions. 

I.     General  Intelligence,  Knowledge  and  Judgment 

The  question  of  intellectual  level  will  probably  have  been  already 
considered  in  the  general  anamnesis.  If  necessary,  the  inquiry 
may  be  supplemented  here  along  the  following  lines: 

Learning  at  school  easy  or  hard 

Standing  in  classes        Failure  of  promotion 

Specially  smart  in  certain  subjects 

Attention  and  concentration  (at  school  and  later) 


23 

Education  commensurate  with  opportunities 

Good  observer        Reason  well 

Considered  to  have  good  common  sense 

Capable  in  positions 

Quick,  impulsive  or  deliberate  in  judgments 

Definite  or  vague  plans  as  to  career,  etc. 

Foresight   in   planning 

Practical        Good  or  bad  manager 

Use  of  tools  or  mechanical  devices 

II.  Output  of  energy 

As  a  child  lively  and  active  at  play  or  work — or  sluggish  and 

lazy 

Naturally  talkative  or  inclined  to  be  quiet  or  silent 
Hard  worker,  energetic,  hustler 
Or  slow,  sluggish,  deliberate,  or  intermediary 
Tendency  to  over-activity — too  much  push  or  tension 
Over-active  or  inactive  by  fits  and  starts 
Interests  in  athletics,  sports,  and  recreations 

III.  General  Attitude  Toward  Environment 

Play  freely  as  a  child 

Bashful  or  at  ease  with  strangers 

Sociable,  easy  to  get  acquainted,  many  friends 

Or  distant,  aloof,  preference  to  be  alone 

Selfish,  generous,  kind-hearted 

Tactless,  faultfinding,  able  to  work  with  others  or  not 

Stubborn  and  insistent  about  having  own  way 

Trustful  or  suspicious,  holding  grudges 

Easily  offended,  see  slights  when  none  was  intended 

Adapt  easily  to  new  situations   (as  when  away  from  home, 

moving  to  new  places,  change  of  work,  etc.) 
Any  marked  differences  in  behavior  in  the  home  or  outside 
General  range  of  interests,  wide  or  narrow 

IV.  Attitude  Toward  Self:    Inner  Mental  Life 

Reveal  much  of  inner  life — personal  views,  aims,  ambitions, 

mental  conflicts,  etc. 

Frank  and  open,  or  reserved,  reticent  and  shut-in 
Tendency  to  talk  and  unburden  self  or  not 


24 

Over-conscientious    and    particular,    or    finicky    and    over- 
scrupulous 

Tendency  to  shirk,  evade,  or  procrastinate 

Honest  and  truthful  or  inclined  to  lie  and  decieve 

Egotistical,  vain,  proud 

Self-reliant — a  leader  or  inclined  to  be  led 

Self-assertive  or  submissive 

Courageous  or  cowardly 

Affectionate,  demonstrative  or  cold 

Many,  few  or  no  friends 

Attracted  by  what  qualities  in  others 

Family  attachments — strong  or  slight 

Marked  fondness  or  antagonism  for  any  member  of  family 
(father,  mother,  brother  or  sister,  or  other  relatives) 

Any  marked  change  in  family  ties  between  childhood   and 
adult  life 

Reaction  to  death  of  members  of  the  family 
(See  also  under  Mood) 

V.  Attitude  Towards  Reality 

Matter  of  fact  or  unimaginative 

Over-imaginative,  visionary,  daydreaming,  phantastic 

Dissatisfied  with  things  as  they  are 

Absent-minded 

Interest  in  occult,  abstract  and  mystical  subjects 

Superstitious 

Religious  interests 

Interest  in  sciences  and  natural  phenomena 

Logical  and  orderly  in  thinking      Or  the  reverse 

VI.  Mood:    Emotional  Reactions 

Placid,  even-tempered,  or  phlegmatic 

Cheerful,  light-hearted,  optimistic 

Or  gloomy,  pessimistic,  worrisome,  looking  on  the  dark  side 

of  things 

Irritable,  easy  angered,  tantrums  and  explosive  outbursts 
Changeability  of  mood — periods  of  buoyancy  or  despondency 
Tendency  to  brooding 
Easily  frightened 
Tendency  to  anxiousness  and  forebodings 


Sensitive,  touchy,  grumbling  or  faultfinding 
Reaction  to  failures,   disappointments,  business  troubles,  re- 
sponsibility, deaths  of  relatives  or  friends 
On  the  other  hand,  reaction  to  good  news,  success,  pleasure 
Crave  sympathy  in  trouble,  seem  to  enjoy  discomforts 

VII.  Sexual  Instincts 

Frank  or  secretive  about  sexual  matters 

Attitude  toward  opposite  sex  or  own  sex 

Natural  or  shy  in  presence  of  opposite  sex 

Many,  few  or  no  love  affairs 

Reaction  to  disappointments  in  love 

Decided  or  uncertain  when  confronted  with  questions  of  en- 
gagement or  marriage 

In  married  life,  well  adapted 

Attitude  toward  the  partner — affectionate  and  kind,  or  dis- 
satisfied, faultfinding,  irritable  and  jealous,  or  domineering 
— or,  on  the  other  hand,  very  submissive 

Desire  for  children  or  not 

Sexual  demands  great  or  small 

Potency,  psychic  impotence,  ejaculatio  prsecox,  frigidity 

Masturbation — age  and  frequency 

Any  perversions 

Sexual  curiosity — fondness  for  gossip  about  sexual  matters 

Excessive  modesty  or  prudishness 

Special  demand  for  neatness,  cleanliness  or  moralizing 

Intolerance  of  sexual  topics  and  easily  disgusted 

Idiosyncrasies  toward  food  or  odors 

Special  tendencies  to  cruelty 

VIII.  Feeliny  of  Inferiority 

Many  of  the  traits  already  considered  may  be  related  to  a  con- 
scious or  subconscious  inferiority  complex.  Direct  or  compensatory 
reactions  to  somatic  and  psychic  inferiority  are  manifold.  Among 
the  more  important  the  following  may  be  mentioned : 

Self-depreciation,  humility,  social  deference,  sensitiveness,  seclu- 
siveness,  dissatisfaction,  jealousy,  criticism,  stubbornness,  coward- 
ice, etc. 


26 

Selfishness,  conceit,  self-pity,  hypochondriasis,  blaming  others  for 
one's  faults,  lack  of  respect  for  others,  undue  emphasis  on  dislike 
of  sham,  etc. 

Unusual  demonstrativeness,  altruism,  generosity,  courageousness, 
etc. 

IX.    Summary  of  Personality  Traits 

At  the  conclusion  of  the  inquiry  into  the  make-up  a  brief  sum- 
mary should  be  made  of  the  various  traits  and  habitual  or  preferred 
reactions  which  are  most  characteristic  of  the  individual  under 
consideration. 


28 


PHYSICAL  EXAMINATION  GUIDE 

(Synopsis) 
INTRODUCTION 

I.  GENERAL,  TYPE,  APPEARANCE  AND  CONDITION 

II.  THORACIC  ORGANS 

III.  DIGESTIVE  AND  ABDOMINAL  ORGANS 

IV.  GENITO- URINARY  ORGANS 
V.  NERVOUS  SYSTEM 

1.  General  and  Subjective  Sensations 

2.  Cranial  Nerves 

3.  Cutaneous  Sensibility 

4.  Vasomotor  and  Trophic  Conditions 

5.  Motor  -Funetions 

6.  Reflexes 

7.  Myopathies 

8.  Fibrillary  Twitchings 

9.  Tremor 
10.  Speech 

1.1.     Organic  Reflexes 
12.     Convulsions 

VI.     VEGETATIVE  NERVOUS  SYSTEM 
VII .     ENDOCRINE  GLANDS 
VIII .     SUMMARY  OF  PHYSICAL  EXAMINATION 


PHYSICAL  EXAMINATION  GUIDE 

Introduction  It  cannot  be  too  strongly  emphasized 
that  all  psychiatric  cases  require  a  careful  physical  exam- 
ination. This  is  obviously  necessary  in  the  first  place  for 
the  purpose  of  determining  if  the  patient  is  suffering  from 
any  injury,  physical  disease,  or  impairment  of  general 
health.  But  bodily  disorders  may  be,  and  often  are,  im- 
portant factors  in  causing  or  maintaining  a  psychosis  and 
the  indications  for  treatment  may  depend  chiefly  on  the 
results  of  the  physical  examination.  In  the  second  place,  a 
careful  physical  examination  is  necessary  for  the  purpose 
of  determining  if  there  are  present  any  signs  and  symptoms 
which  are  characteristic  of  certain  types  of  mental  disorder. 
The  correct  diagnosis  of  the  psychosis  will  in  many  cases 
depend  largely  on  the  physical  findings,  particularly  in 
mental  conditions  due  to  disease  of  the  nervous  system. 

Some  of  the  most  common  and  also  the  most  serious  mis- 
takes which  physicians  make  a^e  due  to  their  failure  to 
discover  and  correctly  interpret  significant  physical  signs 
and  symptoms  in  the  early  stages  of  various  mental 
disorders. 

The  lack  of  cooperation  and  even  opposition  to  examin- 
ation which  mental  patients  often  exhibit  make  the  task 
of  the  physician  doubly  difficult  and  not  infrequently  tax 
severely  his  resourcefulness  and  patience.  The  method  of 
approach  and  the  technique  of  examination  are,  therefore, 
extremely  important  matters  if  satisfactory  results  are  to 
be  obtained  from  the  physical  examination  of  mental 
patients. 

The  following  physical  examination  guide  presents  in 
condensed  form  the  standard  requirements  for  a  fairly 
thorough  examination  of  the  various  organs  and  functions. 
In  some  cases  additional  tests  and  further  investigations 
will  be  necessary  to  clear  up  complex  or  obscure  conditions. 


30 

The  amount  of  time  devoted  to  the  different  aspects  of  the 
examination  will  naturally  vary  with  the  character  of  the 
case. 

For  convenience  of  bedside  work  a  printed  "Outline" 
or  blank  may  be  used,  Form  34-Medical.  Space  is  provided 
on  this  printed  blank  for  the  writing  in  of  the  findings  which 
are  then  copied  into  the  typewritten  case  record.  This 
blank  is  based  on  the  guide,  follows  the  same  order  of  ar- 
rangement, and  covers  the  minimum  requirements  for  the 
initial  physical  examinations  of  new  cases.  It  is  expected 
that  the  physician  who  uses  the  blank  form  will  also  thor- 
oughly familiarize  himself  with  the  following  "Guide"  as 
this  gives  helpful  directions  for  making  the  physical  exam- 
ination as  well  as  some  hints  of  diagnostic  value. 


PHYSICAL  EXAMINATION 
I.     GENERAL  TYPE,  APPEARENCE  AND  CONDITION 

1.  Anthropological  Make-up 

(a)  Height  Weight  (present) 

(b)  Malformations  and  asymmetries:  skull,  face,  ears,  palate, 

body,  spine,  thorax,  pelvis,  hands,  feet,  sexual  organs. 

(c)  Osseous  system:  general  stature,  frame  and  skeletal  type. 

Abnormalities  in  height,  size  of  head,  face  and  jaw 
bones,  setting  of  teeth. 

Disproportion  between   size  of   extremities  and   trunk. 
Torso-leg  ratio  (by  measurement). 

2.  Nutrition 

Usual    weight:    subcutaneous    fat,    amount   and   distribution 
Muscles,  tone  and  size 

3.  Skin,  Hair  and  Nails 

Color  and  texture  of  skin,  general  complexion,  color  of  eyes 
Anaemia,  jaundice,  bronzing,  dropsy,  pallor,  flushing,  cyanosis, 

eruptions,  trophic  disorders 
Hair,  color,  quantity,  unusual  distribution 
Nails,  appearance  and  condition 

4.  Glandular  System 

Lymphatic,  salivary,  thyroid,  thymus,  mammary  glands 

5.  Mouth,    Teeth  and  Naso-Pharynx 

Mucous  membranes,  tongue,  gums,  fetor,  pyorrhoea 
Teeth,  condition  and  number  missing 
Tonsils  and  adenoids 
Naso-pharynx 

6.  Chronic  or  Acute  Diseases 

(a)  Temperature,  pulse  and  respiration 

(b)  Scars,  bruises  and  injuries  (to  be  carefully  noted  and 

fully  described) 

(c)  Evidence   of   syphilis:    scars,   mucous  patches,    glands, 

tibial  crests  and  exostoses  of  skull.    Date  of  infection, 
how  treated 

(d)  Signs  of  gout,  rheumatism  or  tuberculosis  (other  than 

respiratory) 

(e)  Acute  infections,  local  or  general  signs 


32 

II.    THORACIC  ORGANS 

1.  Circulatory  Organs:     Is  there  any  palpitation  In  attacks  Due 

to  what  Subjective  sensation  of  arhythmia  Dyspnoea 
Oedema  Any  attacks  of  pain  or  anxiety 

Heart:  The  impulse  seen  and  felt  in  what  area  Relative 
dullness  (right,  upper  and  left  borders)  Give  measurement 
from  median  line,  beside  the  statement  as  to  nipple-line ;  in 
pathological  cases  draw  a  chart 

Sounds  and  bruits  (localized)  Pay  special  attention  to  muffling 
of  the  first  sound,  to  duplication ;  to  change  of  murmurs  on 
inspiration  and  by  position  and  to  rhythm  and  accentuation, 
and  indicate  graphically  sounds  and  murmurs 

Radial  pulse:  Rate,  quality,  on  lying  and  sitting  and  standing 
Special  attention  to  variability,  through  position  or  emotion 
or  exertion  If  desirable,  sphygmogram 

Condition  of  vessels:  Radial,  brachial  and  temporal  arteries 
Arcus  senilis  Sclerosis  of  veins  Varicosities  Pulsations  of 
neck 

Blood  pressure:  Systolic  and  diastolic,  lying  and  sitting  Ex- 
amination of  the  blood  where  indicated 

2.  Respiratory  Organs:     Is  there   any   difficulty   of  breathing, 

permanent  or  in  attacks  Any  pain  on  deep  inspiration 
Any  cough  or  expectoration  History  of  hemorrhage  Naso- 
'  pharynx  obstructions  or  other  abnormalities  Larynx, 
hoarseness  or  other  symptoms 

Shape  and  elasticity  of  chest:  Expansion,  frequency  of  res- 
piration Respiratory  movements  (compare  both  sides  in 
deep  inspiration  and  expiration) 

Lungs:  Palpation,  percussion,  auscultation  Aspiration  of 
pleural  cavity  when  indicated 

III.    DIGESTIVE  AND  ABDOMINAL  ORGANS 

Appetite,  thirst,  anorexia,  nausea;  relation  to  quantity  and 
quality  of  food  Vomiting  (time  and  form)  ;  eruptions  and 
brashes;  pain  (locality,  irradiation  and  time) 

Abdomen:  Flat,  soft,  distended,  pain,  tenderness,  rigidity, 
retraction 


33 

Abdominal  organs:    Stomach  and  liver  outlines;  gall  bladder; 

spleen ;  floating  kidney 
Digestion      Movements  of  bowels      Any  subjective  feeling  of 

obstacles        Form    of    stools        Flatulence    and    distention. 

Constipation,  hemorrhoids  and  fistulas 
If  indicated — examination  of  stomach  contents  and  feces 

IV.     GENITOURINARY  ORGANS 

Micturition:  Urine — amount  in  24  hours,  specific  gravity, 
color,  reaction,  odor,  albumen,  sugar  and  indican  and  diazo 

Macroscopic  and  microscopic  examination  of  sediment,  clouds 
and  threads;  casts,  epithelia,  erythrocytes,  leucosytes,  bac- 
teria, threads,  crystals,  amorphous  substances  (special  chart) 

In  women:  Menstruation  (regularity  and  type;  duration  and 
amount  and  probable  cause  of  abnormalities)  ;  accompanying 
symptoms  (pains  and  especially  nervous  symptoms)  Evi- 
dences of  menopause 

Discharges  at  intervals;  constant,  profuse,  color 

Internal  examination:  findings,  their  history  and  possible 
relation  to  the  rest  of  the  status  (Gynaecological  chart) 

In  men:  Frequency  and  character  of  the  sexual  functions 
Frequency  of  emissions,  their  exciting  causes  and  correlated 
symptoms 

Masturbation — the  reaction  to  it  is  the  most  important  point 

Penis,  scars,  ulcers,  discharge  (make  smears  if  indicated) 

V.    NERVOUS  SYSTEM 

1.      General  and  Subjective  Sensations 

General  feeling  of  well  being  or  exhaustion,  general  complaints, 

weakness,  etc. 
Vertigo:  Constant,  occasional,  or  occurring  on  definite  changes 

of  position,  when  the  patient  walks  or  in  the  dark 
Headache:     Whole  head  or  limited  space;   frontal,  vertical, 

bi-temporal,  occipital,  constant,  or  periodic,  aggravated  at 

night  or  by  some  special  cause,  as  with  heat ;  with  or  without 

tenderness  of  head  or  spine  to  touch  or  pressure 
Pains:     Ovarian,   infra-mammary,  lumbar  and  vertex  pains 

(in  hysteria) 
Neuralgic  pains  (5th  nerve),  intercostal  nerves,  sciatic  nerve, 

with  pain  points,  etc.,  and  muscular  pains 


34 

General  or  wandering  pains :    Prascordial  pains  with  or  without 

anxiety    Sudden  shooting  pains 
Pains  in  bones  (legs),  afternoon  or  night 
Girdle  pains:    Zones  of  hyperaesthesia  (See  following  under  3) 

Cranial  Nerves 

1st  Nerve:     Smell     Anosmia,  paranosmia     Test  each  nostril 

separately    Defects  may  be  mental,  nervous  or  local 
2nd  Nerve:       Vision       Acuity,  dimness,  limitation  of  field, 

scotoma,   hemianopsia,    color  sense     Eye-grounds  ophthal- 

moscopic  examination    Corneal  scars    Cataract 
3rd,  4th  and  6th  Nerves:    (Eyelids,  muscles  and  pupils)     Test 

for  ptosis,  nystagmus,  ocular  palsies,  squint,  double  vision, 

convergence,  exophthalmos,  enophthalmos,  size  of  palpebral 

fissures 
Pupils:    Size,  shape,  outlines,  adhesions  of  iris,  inequality  of 

pupils    Reaction  to  light  and  in  accommodation ;  consensual, 

sympathetic,  and  psycho-reflexes 
5th  Nerve:    (motor  portion)  muscles  of  mastication,  masseters, 

temporals,  and  pterygoids  (sensory  portion)  face  and  anter- 
ior scalp,  conjunctiva,  mucous  membranes 
Taste  anterior   ^  tongue  (see  9th  N.) 
Neuralgia  or  facial  pains  in  distribution  of  nerve  should  be 

inquired  for 
7th  Nerve:    Muscles  of  forehead,  face,  mouth  and  orbicularis 

oculi 
8th  Nerve:    Hearing     (cochlear  portion)  test  acuity  of  hearing 

Differentiate   central,   peripheral,   and   functional   deafness 

Tinnitus  and  ear  noises    Unilateral  hallucinations  of  hearing 

may  correspond  to  diseased  ear  (vestibular  portion)  eqai- 

librium,  vertigo 

Otoscopic  examination:     External  canal  and  drum 
9th  Nerve:     Deglutition  and  sensation  back  of  tongue  and 

upper  pharynx 

Taste:     (together  with  5th  nerve)     Test  separately  anterior 
y$  supplied  by  5th  N.  and  posterior  YJ,  supplied  by  the 

9th  N. 
10th  Nerve:     Test  muscles  of  soft  palate  and  larynx     Note 

disturbances    in    phonation,    respiration    and   heart    action 

Laryngoscopic  examination  if  indicated 


35 

llth  Nerve:  Test  action  of  sterno-mastoid  and  trapezius 
muscles  Position  and  movements  of  the  head  and  scapulae 

12th  Nerve:  Muscles  of  tongue  Protrusion  and  other  move- 
ments, atrophy  and  tremor 

3.  Cutaneous  and  Deep  Sensibility:  (A  few  tests  of  localization 
of  touch  and  pain  sensations  obligatory,  to  exclude  hysteria ; 
in  all  cases  with  subjective  complaints  or  where  any  indica- 
tion and  doubt  exists,  complete  examination  is  advised) 

Subjective  complaints:     (formication,  feeling  of  needles 
and  pins,  numbness) 

Tactile  sensibility:  (use  the  finger  tip,  cotton,  or  pin) 
Compare  both  sides  of  face,  arms,  hands,  fingers,  breasts, 
inner  and  outer  aspects  of  thighs  and  legs  Never  omit 
the  ulnar  side  and  the  area  outside  and  above  the  knee, 
the  sole  and  dorsum  of  foot  and  in  hysteria  the  breast 
and  other  points  of  predilection  of  hysterical  anaes- 
thesia 
Localization  of  touch  (time  and  space)  and  tickle 

Sensibility  to  pain:  (cautious  pricks  with  a  pin,  localiza- 
tion in  time  and  space),  with  or  without  the  attention 
of  the  patient 

Sensations  of  heat  and  cold:  (cold  water  and  warm  water 
in  a  glass  tube)  Pain  and  temperature  sense  may  be 
lost  without  any  other  sensory  disorder  in  syringo-myelia 
and  in  lesions  of  the  lateral  columns  of  the  cord,  and 
rarely  in  hysteria  These  disorders  may  occur  without 
any  other  sensory  defect 

Stereognostic  sense:  Does  the  patient  recognize  two  or 
three  dimensions,  and  objects  from  mere  palpation  with 
the  eyes  closed — of  special  importance  for  the  study  of 
disturbances  of  sensory  elaboration  in  the  parietal  cortex 

Sense  of  position:    Best  studied  with  the  motor  functions 

Tenderness  of  nerve  trunks  and  muscles  on  pressure  and 
percussion:  The  distributions  to  be  noted  on  the  draw- 
ings of  the  body  surface 

Biernacki's  sign  (analgesia  of  the  ulnar  nerve)  ;  anaesthesia 
of  eye-ball,  of  testicles 


36 

4.  Vasomotor  and  Trophic  Conditions 

Salivation,  seborrhcea 

Cyanosis  or  pallor;  scaliness  or  glossy  appearance  of  skin; 

loss  of  hair ;  change  of  nails 

Blushing,  dermatograpJiia      General  and  localized  perspiration 
Temperature  of  paralyzed  or  anaesthetic  parts 

5.  Motor  Functions 
Right  or  left-handed 

Any  paresis  or  paralysis  apparent  or  established  by  testing 
the  functions  of  successive  segments 

Motility  of  facial  muscles  (wrinkle  forehead,  close  eyes  tightly, 
show  teeth,  purse  lips,  whistle)  and  movements  of  jaw, 
tongue,  palate,  etc.  (See  under  Cranial  Nerves)  Test 
strength  of  muscles  of  neck,  shoulder  girdle,  trunk  and  ex- 
tremities 

Upper  limbs:  Compare  hand  grips,  strength  of  flexors,  exten- 
sors and  rotators 

Lower  limbs:  Rise  on  toes,  elevate  toes,  flex  and  extend 
feet,  legs  and  thighs  Elevate  both  legs  from  bed  and  hold 
to  fatigue  limit — weaker  limb  sinks  first 

Gait:  Observe  walking,  turning,  stopping  and  starting  Note 
limping,  shuffling,  straddling,  stamping,  ataxia,  steppage, 
propulsive  tendencies,  etc. 

Coordination:  Writing,  buttoning  coat  and  picking  up  objects 
Finger-nose,  finger-finger  and  heel-knee  tests 

Balancing:  Walk  straight  line;  stand  with  eyes  closed,  heels 
and  toes  together  (Romberg  position)  ;  steady,  sways  or  falls 

Muscle  Sense:  Discrimination  of  differences  in  weight;  with 
eyes  closed  tell  the  position  of  limbs ;  appreciation  of  passive 
movements,  show  by  one  side  the  position  of  the  limb  of  the 
other  side 

6.  Reflexes 

(a)  Deep  reflexes:  Masseteric;  elbow,  wrist,  thumb,  and  knee 
jerk ;  latter  with  or  without  reinforcement,  with  clonus, 
or  contralateral  adductor  reflex;  knee  cap  reflex  (tap- 
ping the  finger  which  pulls  down  the  patella  in  the  lying 
position,  usually  giving  a  better  idea  of  differences  of 
the  two  sides)  Ankle  clonus  (one  or  several  catches, 
or  a  continuous  clonus) ;  Achilles  tendon  reflex 


37 

(b)  Superficial  reflexes:  Planter  (with  full  description  as  to 
to  the  Babinski  reflex),  gluteal,  cremasteric,  abdominal, 
epigastric,  scapular,  corneal,  palmar,  pharyngeal, 
sneezing  Sexual  reflexes  (see  under  11) 

7.  My  apathies 

Examine  carefully  weak  muscles,  or  those  not  responding  in 
reflexes,  whether  they  are  firm  and  of  good  tone,  or  flaccid  or 
deficient  in  tone,  or  rigid  and  contracted  Note  attitude  of 
limb  and  the  limitation  of  the  motion,  active  and  passive, 
in  every  joint 

Atrophy      Hypertrophy 

Electrical  reactions  when  indicated  of  nerve  and  muscle; 
mechanical  irritability 

8.  Fibrillary   Twitchings 
Describe  and  give  distribution 

9.  Tremor 

Of  what   parts,   face,   tongue,   fingers,   etc.     Describe   as  to 

rhythm,  intensity,  rapidity 

Condition  at  rest,  during  sleep ;  when  first  observed 
Condition  during  motion,  how  influenced  by  will 
A  sample  of  writing  should  always  be  obtained  and  inserted 

in  the  history,  (name,  date  and  test  phrase) 

10.  Speech 

Note  any  defect  in  ordinary  conversation 

Speech  tests  are  to  be  tried  in  every  case  (third  riding  artil- 
lery brigade;  particular  popularity;  electricity;  Methodist 
Episcopal;  army  reorganization;  truly  rural) 

11.  Organic  Reflexes  and   Their  Control 

Bladder:  Delay  of  micturition  Dribbling  from  empty  blad- 
der, from  distended  bladder  Peculiar  sensations  on 
micturition 

Sexual  reflexes:  Frequent  involuntary  contraction  and  evac- 
uation 

Defecation:    Is  the  patient  conscious  of  evacuations 


38 

12.      Convulsions 

Duration  and  frequency:  Occurring  night  or  day,  or  in  early 
morning  Initial  cry,  scream  or  other  symptoms  Extend 
over  head,  trunk  and  extremities,  or  one  side  or  one  member 

Character:  Which  parts  first  and  most  attacked  and  how  do 
the  waves  of  the  tonic  and  clonic  spasm  spread  What 
movements  predominate  Is  a  paralyzed  part  omitted  or 
involved 

Observe  breathing ;  pupils ;  vasomotor  conditions ;  whether  there 
is  frothing  and  biting  or  talking  during  attack  Relaxation 
of  sphincters 

Consciousness  totally  or  partially  lost 

Aura:    Character,  location  and  spread 

Equivalents  with  or  without  what  automatic  movements 

Psychical  and  nervous  symptoms  before  and  after  attack 

Vomiting,  headache,  sleep,  coma 

VI.    THE  VEGETATIVE  NERVOUS  SYSTEM 

Supplies  the  involuntary  or  smooth  muscle  organs.  Evidence 
of  disturbance  infunction  may  have  been  observed  in  the  preceding 
examination  of  the  voluntary  nervous  system  and  viscera.  It  is 
advisable,  however,  to  call  attention  here  to  some  of  the  more 
striking  signs  and  symptoms  which  are  considered  to  indicate 
alteration  of  function  of  the  vegative  nervous  system.  Among 
these  are: 

(a)  Sympathetic  Division:    Signs  of  over-activity  are  warm, 

dry  skin ;  wide  pupils ;  rapid  heart ;  hyper-sensitiveness 
to  adrenalin  (a  sympathetic  stimulant) 
Cervical  Sympathetic:  Paralysis  gives  characteristic 
symptoms:  drooping  of  lid  without  loss  of  voluntary 
control;  small  pupil,  not  dilating  when  shaded,  but 
contracting  to  light;  enophthalmos,  with  narrowing  of 
fissure;  loss  of  cilio-spinal  (sympathetic)  reflex;  failure 
of  pupil  to  dilate  under  cocaine 

(b)  Automatic  Division:    Signs  of  over-activity  are  cool,  pale, 

moist  skin ;  small  pupils ;  slow  heart ;  gastric  hyperacid- 
ity; sluggish  bowel  action;  hyper-sensitiveness  to 
pilocarpine  (a  vagus  stimulant) 


39 

VII.     ENDOCRINE  GLANDS 

Evidence  of  disturbances  may  have  been  found  and  recorded 
under  other  headings.  But  such  evidence  may  be  brought  to- 
gether at  this  place  to  focus  attention  on  important  symptom- 
complexes.  The  special  guide  for  the  study  of  endocrine  disorders 
should  be  used  in  suitable  cases  or  where  special  investigation  of 
the  body  development  and  endocrine  system  is  undertaken. 

Thyroid 

(a)  Hyperthyroidism:      tachycardia;    tremor;    perspiration; 

gastro-intestinal  over-activity ;  eye  symptoms ;  excessive 
reaction  to  adrenalin  (Gffitsch  test)  ;  low  carbo-hydrate 
tolerance. 

(b)  Hypothyroidism:     (1)  Myxedematous  type  shows  brady- 

cardia;  skin,  hair  and  nail  changes;  gastro-intestinal 
sluggishness;  high  carbohydrate  tolerance;  diminished 
reaction  to  adrenalin.  (2)  Cretin  type  shows  mental 
and  physical  deficiency  with  symptoms  of  myxedema. 

Pituitary 

(a)  Hyper  function — Onset   after   puberty   gives   acromegalic 

type:  enlargement  of  bones;  thickened  mucous  mem- 
branes; enlarged  tongue;  muscular  atrophies;  super- 
abundant hair;  alteration  in  sexual  functions;  reduced 
carbo-hydrate  tolerance. 

Onset  before  maturity  gives  giant  type :  increased  length  of 
bone;  precocious  development  of  sexual  instinct  and 
organs  of  reproduction. 

(b)  Hypofunction — (Froehlich's     Syndrome)     with    obesity; 

general  deficiency  of  hair ;  infantile  sexual  organs ;  short 
stature;  increased  carbohydrate  tolerance. 

Testicle 

Hypofunction:     eunuch  type  shows  absence  of  testicle; 

obesity ;  feminine  hair  distribution ;  lack  of  development 

of  external  genitalia. 
Eunuchoid  type  shows  deficiency  of  secretion;  essentially 

same  signs  as  in  eunuch. 

Ovary 

Hypofunction  .-Delayed  puberty;  infantile  uterus;  delayed 
or  disordered  menstruation;  obesity. 


40 

Adrenal 

(a)  Hyper/unction:      (  ?)     increased    blood    pressure;    low 

carbohydrate  tolerance;  glycosuria. 

(b)  Hypo  function:    Skin  pigmentation;  low  blood  pressure; 

asthenia,   (Addison  Syndrome). 
Status  Lymphaticus:     (Related  to  thymus  or  adrenal?) 

Slender  frame;  feminine  contour;  feminine  hair  distri- 
bution; smooth  skin;  hyperplasia  of  lymphatic  system. 

VIII.    SUMMARY  OF  PHYSICAL  EXAMINATION 

The  physical  findings  are  to  be  summarized  not  merely  in  the 
order  of  examination  but  especially  in  order  of  importance  or 
evolution  and  in  differential  diagnosis.  Symptoms  which  make 
up  a  characteristic  symptom-complex  should  be  grouped  together 
in  the  summary.  Attention  should  be  called  to  points  for  further 
investigation. 

Indications  for  treatment  should  be  added. 


42 


BODY  DEVELOPMENT  AND  ENDOCRINE  GLANDS 

(Synopsis) 
INTRODUCTION. 

1.  GENERAL  DEVELOPMENT:    Height,  Weight,  Body  Con- 

tour, Nutrition. 

2.  HEAD:      Face,    Eyes,    Glabella,    Nose,    Ears,    Jaws, 

Palate,  Teeth. 

3 .  NECK  :    Thyroid  Gland. 

4 .  SPINE 

5 .  THORAX 

6 .  ABDOMEN 

7 .  PELVIS 

8 .  EXTREMITIES 

9.  MUSCULAR  DEVELOPMENT 

10.  SKIN 

11.  HAIR 

12.  CARDIO- VASCULAR  SYSTEM 

13.  LYMPHATIC  SYSTEM:     Tonsils  and  Other  Lymphoid 

Structures. 

14.  SEXUAL  ORGANS 

15.  SUBJECTIVE  SENSATIONS 

16 .  DRUG  REACTIONS  :    Pilocarpine,  Atrophine,  Adrenalin. 

17.  LABORATORY  TESTS:    Blood,  Sugar  Tolerance,  X-Ray. 

18.  ENDOCRINOPATHIES  IN  FAMILY 

19.  DEVELOPMENTAL  HISTORY:    Growth,  Weight  Changes; 

Sexual  Function,  Etc. 

20.  SUMMARY  OF  FINDINGS 


BODY  DEVELOPMENT  AND  ENDOCRINE  GLANDS 

Introduction:  This  guide  is  offered  tentatively  for  use 
in  special  investigation  of  body  development  and  of  the 
glands  of  internal  secretion  to  supplement  the  usual  phy- 
sical examination  guide.  It  is  not  meant  to  take  the  place 
of  this  latter,  but  is  intended  to  give  in  more  detail  direc- 
tions for  investigating  the  relation  of  body  development 
and  endocrine  make-up  to  physical  or  mental  disease.  Form 
128  medical  is  a  printed  blank  or  outline  based  on  the 
guide  and  is  intended  for  use  in  the  individual  clinical 
examinations  or  bedside  work  in  about  the  same  manner 
as  the  printed  blank  Form  34  medical,  is  used  in  making 
the  ordinary  physical  examination. 

This  guide  and  the  outline  (Form  128  medical)  should  be 
supplemented  in  individual  cases  by  information  obtained 
in  the  anamnesis  regarding  the  physical  characteristics  and 
susceptibility  to  disease  of  the  family  and  also  the  develop- 
mental history  of  the  patient. 

In  arranging  the  guide  the  standard  textbooks  and  var- 
ious special  articles  have  been  consulted;  most  assistance 
has  been  obtained  from  the  publications  of  Dr.  Walter 
Timme,  including  the  examination  scheme  devised  by  him 
and  used  at  the  New  York  Neurological  Institute. 

1.  GENERAL  DEVELOPMENT:  Careful  estimation  of  the 
height  of  the  patient  is  to  be  made.  The  trunk  length  is 
the  length  in  inches  between  the  suprasternal  notch  and  the 
anterior  superior  spine  of  the  ilium.  The  leg  length  is 
the  length  in  inches  between  the  anterior  superior  spine  of 
the  ilium  and  the  internal  malleolus. 

In  a  properly  proportioned  person  the  leg  length  is  twice 
the  trunk  length  (torso-leg  ratio).  It  has  been  observed 
that  in  hypo-function  of  the  pituitary  the  trunk  is  compar- 
atively longer  than  the  extremities;  in  deficiency  of  the 


44 

internal  secretion  of  the  sex  glands  it  has  been  observed 
that  the  leg  length  is  longer  in  proportion  than  the  trunk 
length.  Certain  other  relations  between  these  measure- 
ments may  be  noted  with  other  developmental  or  endocrine 
abnormalities. 

The  arm  span  is  the  distance  between  the  right  and  left 
middle  finger  tips  when  the  arms  are  extended  horizontally 
sideways,  and  in  well  proportioned  individuals  approxi- 
mately equals  the  height.  About  the  same  disproportion 
between  the  arm  span  and  the  height  has  been  noted  as  in 
the  torso-leg  ratio  in  the  conditions  mentioned  above.  The 
arm  span  measurement  is  perhaps  best  taken  by  having  the 
patient  stand  with  the  back  to  the  wall,  the  extended  arms 
in  a  sideways  horizontal  position,  with  the  middle  finger-tip 
of  one  arm  at  the  zero  point  on  a  scale  in  inches;  the 
opposite  middle  finger-tip  marking  off  the  span  distance. 

Weight:  A  variation  from  the  usual  weight  may  indicate 
riot  only  chronic  visceral  disease  but  also  an  alteration  in 
endocrine  function;  for  example,  an  increase  or  loss  of 
weight  may  indicate  decrease  or  increase  of  thyroid 
function,  an  alteration  of  function  of  the  sexual  organs  or 
of  the  pituitary. 

Body  Contour:  Is  to  be  noted  as  masculine  or  feminine 
as  the  relation  of  shoulders,  waist  and  hips  and  the  in- 
clination of  the  thighs  and  angularity  or  roundness  of 
contours  suggest  the  masculine  or  feminine  type  of  develop- 
ment. 

Nutrition:  To  be  noted  as  poor,  fair,  good,  obese.  This 
indicates  the  amount  of  subcutaneous  fat,  which  may  be 
influenced  by  not  only  environment  and  economic  state  or 
visceral  disease,  but  also  by  endocrine  activity.  For  ex- 
ample, emaciation  may  be  the  result  of  adrenal  hypo- 
function  or  thyroid  hyper-function;  increased  amount  of 
fat  the  result  of  sexual  gland  hypo-function  or  obesity  with 
thyroid  or  pituitary  hypo-function.  The  distribution  of  the 
subcutaneous  fat  is  to  be  noted  as  even,  a  comparatively 


45 

normal  state,  or  if  uneven,  the  locations  of  the  accumula- 
tions of  fat,  particularly  of  the  breasts,  abdomen,  pubis, 
hips  or  extremities  are  to  be  mentioned. 

2.  HEAD:  Circumference  is  to  be  taken  with  a  tape 
passing  through  the  external-occipital  protuberance  and 
across  the  forehead.  The  average  circumference  in  the 
male  is  said  to  be  about  52  cm.,  female  50  cm.,  with  a  normal 
variation  between  48.5  cm.  and  57.4  cm.  (Church  &  Peter- 
son's Nervous  and  Mental  Diseases,  1916  ed.,  p.  699.)  It 
is  said  that  the  volume  of  the  brain  may  be  estimated  from 
the  circumference  by  considering  50  cm.  (20  inches)  as 
equalling  1,350  cc.  of  volume.  (The  formula  would  be — 
volume:  circumference  :  :  1,350  cc. :  50  cm.) 

The  length  is  best  taken  by  calipers  and  is  the  widest 
antero-posterior  diameter.  Average  male  17.7  cm.,  female 
17.2  cm.,  normal  variations  16.5  cm.  to  19  cm. 

The  width  is  the  greatest  transverse  diameter.  Average 
male  width  said  to  be  14.6  cm. ;  female  14  cm.,  normal  var- 
iations 13  to  16.5  cm. 

The  cephalic  index  is  gotten  by  dividing  the  width  by 
the  length,  and  the  head  is  described  as  dolichocephalic 
(long  head)  if  the  result  is  Jess  than  78,  mesocephalic  if 
between  78  and  80,  and  brachy cephalic  (short  head)  if 
greater  than  80.  It  is  said  that  the  physiological  limits  of 
the  index  are  70  to  90. 

Type  of  Face:  Here  are  to  be  noted  not  only  the  general 
shape  of  the  face  (long  or  narrow,  broad  or  short)  'but 
also  the  characteristics  indicating  the  acromegalic,  the  in- 
fantile, the  cretinoid,  the  prematurely  aged  (gerodermic) 
and  Mongolian  types. 

Eyes:  Note  the  comparative  prominence  of  the  eyeballs, 
whether  normal,  or  protruding,  as  in  exophthalmic  goitre, 
or  whether  receding  or  deep-set  (enophthalmus)  a  condition 
which  may  be  found  either  bilaterally  or  unilaterally  in 
paralysis  of  the  cervical  sympathetic.  Exophthalmos  is  to 
be  considered,  on  the  contrary,  to  be  due  to  the  stimulation 
of  the  cervical  sympathetic. 


Inter-pupillary  distance  has  so  far  as  known  no  set  stand- 
ard, but  the  width  or  narrowness  of  this  space  is  indicative 
of  the  type  of  osseous  development. 

The  palpebral  fissure  is  to  be  noted  in  its  width  and 
equality,  or  inequality,  either  of  which  may  be  indicative 
of  abnormal  thyroid  or  sympathetic  function.  The  move- 
ments of  the  eyelids  may  lag  in  sympathetic  stimulation; 
in  cervical  sympathetic  paralysis  there  may  be  a  pseudo- 
ptosis  with  drooping  of  the  eyelids  without  loss  of  voluntary 
elevation. 

Glabella:  The  glabella,  supra-orbital  ridges  and  malar 
eminences  are  to  be  noted  as  to  their  prominence  which 
indicates  a  type  of  bony  development,  particularly  marked 
in  giantism  or  acromegaly;  the  prominence  is  less  marked 
in  pituitary  hypo-function. 

Nose  and  Ears:  Note  as  to  size  and  form  or  shape;  also 
abnormalities  and  asymmetries  in  the  ears. 

Jaws:  The  upper  and  lower  jaws  are  to  be  described 
as  protruding,  straight  or  receding.  These  characteristics 
apparently  vary  with  alteration  in  function  of  the  pituitary. 
Their  width  also  varies  possibly  with  the  function  of  the 
same  gland. 

Palate:  Describe  as  to  its  height  with  abnormalities, 
particularly  the  presence  or  absence  of  maxillary  torus, 
an  elevation  of  bone  in  the  mid-line,  supposed  to  be  indi- 
cative of  pituitary  abnormality. 

Teeth:  Particular  attention  is  to  be  paid  to  the  spacing 
or  crowding  which  is  indicative  of  the  type  of  bony  develop- 
ment. The  condition  of  softness  or  hardness  of  the  teeth 
and  their  preservation  may  also  indicate  deficiencies  of 
development  or  endocrine  disturbance.  Pigmentation,  if 
found,  is  thought  to  be  indicative  of  adrenal  dysfunction. 

3.  NECK:  Describe  as  short,  long,  thick,  thin,  with  cir- 
cumference noted  in  inches.  The  long,  thin  neck  is  found 
in  the  hyper-thyroid  or  thymic  type  of  case,  and  the  short, 
thick  neck  is  possibly  associated  with  pituitary  dysfunction 


or  thyroid  hypo-function.  The  thyroid  should  be  carefully 
palpated  and  described.  Note  the  presence  or  absence  of  a 
thrill  and  bruit,  often  present  in  hyper-function  of  the 
gland. 

4.  SPINE  :     Normal  or  abnormal,  particularly  with  re- 
gard to  scoliosis,  lordosis  or  kyphosis,  and  if  such  conditions 
are  present  determine  whether  they  are  due  to  actual  bone 
disease  or  to  lack  of  muscle  tone.    This  lack  of  tone  may  be 
found  in  deficient  adrenal  states  or  in  the  asthenic  stages 
of  acromegaly  or  in  primary  pituitary  hypo-function. 

5.  THORAX  :     The  long,  narrow,  flat  type,  or  the  short, 
thick  or  barrel-shaped  type.    Persons  with  these  types  are 
said  to  be  variously  susceptible  to  physical  disease  and  to 
have  deficient  endocrine  functions.    The  narrow  sub-costal 
angle  usually  goes  with  the  long  type  of  thorax  and  the 
wide  angle  with  the  short  type.     The  circumference  on 
inspiration  and  expiration  indicates  definitely  the  relative 
size  of  the  chest  compared  with  the  rest  of  the  body,  as 
well  as  the  pulmonary  capacity  and  function. 

6.  ABDOMEN  :    Note  the  type,  whether  scaphoid,  or  mod- 
erately rounded  with  firm  muscle,  or  dependent  and  obese 
the  last  not  infrequently  found  with  pituitary  hypo-function 
arid  indicative  of  lack  of  muscle  tone.    The  girth  of  the  waist 
indicates  the  relative  size  of  the  chest  and  abdomen. 

7.  PELVIS  :    Masculine  or  feminine  in  type,  and  perhaps 
best  definitely  to  indicate  this  are  widths  at  the  crests  and 
the  width  at  the  trochanters.    The  inclination  of  the  thighs 
should  be  observed. 

8.  EXTREMITIES  :    The  proportionate  development  of  the 
extremities  to  the  trunk  should  be  noted,  not  so  much  as  to 
length,  which  has  been  described  under  1,  but  as  to  the  type 
of  bone.    Particular  attention  should  be  given  to  the  relative 
proportion  of  the  hands  and  feet  to  the  upper  portions  of 
the  extremities.    The  distal  portions  of  the  extremities  in 
acromegaly  are  disproportionately  enlarged.    The  reverse 


48 

may  be  true  in  hypo-pituitarism.  The  type  of  hand  or  foot 
is  indicative  also  of  the  type  of  body  development  and 
possibly  of  endocrine  function.  The  arch  of  the  foot, 
whether  high,  low  or  flat,  may  indicate  muscle  tonus. 

9.  MUSCULAR  DEVELOPMENT  :    Describe  the  general  mus- 
cular development  as  poor,  fair  or  good.    Relative  develop- 
ment of  trunk  and  extremities  should  be  observed.    Rapid 
muscle  fatiguability  as  brought  out  by  arm  setting-up  exer- 
cise is  particularly  evident  in  cases  of  hypo-function  of  the 
adrenal  or  in  cases  of  status  lymphaticus.     This  latter 
condition  may  depend  on  the  former. 

Atrophy  or  Hypertrophy  should  be  noted  and  fully  de- 
scribed if  present. 

General  Muscle  Tone :  Investigate  and  note  the  presence 
or  absence  of  hyper-extensibility  of  the  various  joints,  the 
latter  indicating  a  lack  of  muscle  tone  frequent  in  hypo- 
function  of  the  pituitary. 

10.  SKIN  :  Should  be  described  as  dry,  or  moist,  or  oily ; 
warm  or  cool;  smooth  or  rough;  thick  and  coarse  or  thin 
and  fine ;  or  myxedematous ;  with  the  location  of  the  various 
abnormalities,  if  present,  on  the  face,  neck,  trunk,  arms, 
hands,  legs  or  feet. 

Perspiration  should  be  described  as  to  its  amount  and 
whether  uniformly  distributed  or  localized  in  certain  parts 
of  the  body,  such  as  the  face,  axilla,  hands,  perineum  or 
feet. 

Flushing:  Present  or  absent,  general,  or  localized  to 
certain  parts  of  the  body. 

Pallor:    To  be  investigated  the  same  way. 

Urticaria  or  the  presence  of  goose  flesh  and  any  type  of 
eruption  should  be  fully  described. 

Reaction  on  stroking:  Determine  by  moderately  firm 
stroking  with  the  ball  of  the  index  finger  on  the  thorax  or 
abdomen.  The  normal  reaction  is  a  red  line ;  a  red  line  with 
a  white  border  is  said  to  indicate  moderate  adrenal  insuf- 


49 

ficiency,  and  an  entirely  white  line  (Sargent's  Line)  a  more 
marked  degree  of  this  condition. 

Complexion:  Note  whether  albino,  blond,  light  brunette 
or  dark  brunette;  is  said  to  be  of  possible  significance  for 
resistance  to  disease  and  for  endocrine  make-up. 

Pigmentations  of  various  parts  of  the  body,  including 
mucous  membranes  and  points  of  pressure  from  the  clothes, 
may  be  found  in  adrenal  disease. 

Nails  whether  smooth,  rough,  fissured  or  brittle,  may 
indicate  endocrine  abnormalities.  The  hyper-thyroid  type 
is  said  to  have  smooth,  pink  nails;  the  hypo-thyroid  type 
of  nail  is  of  a  dry,  brittle  character. 

11.  HAIR:     The  character,  that  is,  whether  downy,  fine 
or  coarse,  and  the  amount,  whether  absent,  sparse,  thin  or 
thick,  of  various  portions  of  the  head,  trunk  and  extrem- 
ities, are  to  be  described  as  indicating  the  possibility  of 
endocrine  dysfunction.    For  example,  the  acromegalic  type 
is  frequently  hairy.    A  marked  excess  of  thick,  coarse  hair 
is  also  found  in  disorders  of  the  cortex  of  the  adrenals. 
The  deficient  sexual  gland  type  may  have  thick  hair  of  the 
head,  but  a  deficiency  elsewhere  on  the  body,  whereas  the 
hypo-pituitary  type  has  a  thin,  sparse  distribution  of  hair 
throughout. 

12.  CARDIO-VASCULAR  SYSTEM:     In  this  examination  ac- 
quired organic  disease  of  the  heart  is  not  considered,  but 
rather  the  functional  cardiac  action  as  determined  by  in- 
spection, palpation  and  auscultation.     One  may  describe 
the  action  as  weak  or  feeble,  or  normal,  or  excessive. 

Very  important  is  the  investigation  of  the  blood  pressure, 
both  the  systolic  and  diastolic.  Not  only  one  reading  but 
second  and  third  readings  should  be  taken  after  about  two 
or  three  minutes  intervals.  By  this  method  variations  over 
brief  periods  in  the  systolic  and  diastolic  pressures  are 
frequently  noted,  such  variations  perhaps  being  most 
marked  in  the  hyper-thyroid  types  and  in  adrenal  insuf- 


50 

ficiency,  perhaps  in  status  lymphaticus.  The  pulse  in  both 
reclining  and  standing  positions  is  to  be  noted.  Also  im- 
portant as  indicating  the  functional  activity  of  /the  heart 
is  the  increase  in  the  pulse  rate  after  moderate  setting-up 
exercise  of  the  arms,  with  observations  as  to  the  time  re- 
quired for  the  heart  to  return  to  its  previous  rate.  A  lack 
of  prompt  return  after  exercise  indicates  cardiac  irritabil- 
ity or  nervous  instability  (possibly  hyper-thyroidism). 

Cyanosis  of  the  hands  or  feet  should  be  noted  as  indicat- 
ing poor  circulatory  function. 

13.  LYMPHATIC  SYSTEM  :     The  condition  of  the  tonsils, 
adenoids,  and  axillary,  epitrochlear  and  inguinal  lymph- 
nodes  should  be  noted,  these  being  enlarged  perhaps  partic- 
ularly in  cases  of  status  lymphaticus,  although  apparently 
not  necessarily  so.     Thymus  enlargement  may  be  ascer- 
tained by  percussion  or  X-ray. 

14.  SEXUAL  ORGANS:     In  the  male  the  testes  should  be 
described,  whether  descended  or  undescended,  and  their 
size  noted,  and  also  their  consistency,  particularly  to  de- 
termine  atrophy  .with   a   fibrous   condition.     This   latter 
alteration  has   been   described   as   present   frequently   in 
dementia  praecox,  a  claim  which  needs  to  be  checked  up. 
The  size  of  the  scrotum  may  indicate  the  general  muscular 
tone  of  the  body,  being  particularly  lax  and  dependent  in 
cases  of  hypo-function  of  the  pituitary.    It  may  of  course 
be  quite  small  in  deficient  sexual  development.    The  latter 
statement  also  applies  to  the  penis. 

Female:  Careful  gynecological  examination  is  to  be 
made  to  ascertain  particularly  the  size  of  the  uterus  and 
the  development  of  the  external  genitalia.  The  condition 
of  the  menstrual  function  is  also  to  be  carefully  noted, 
obtaining,  if  possible,  the  history  regarding  this. 

15.  SUBJECTIVE  SENSATIONS  :    It  is  considered  advisable 
to  note,  if  obtainable  from  the  patient,  subjective  bodily 
sensations,  particularly  cold,  warm,  or  hot  sensations  in  the 


51 

skin,  constant  or  variable,  including  hot  flashes.  Feelings 
of  general  weakness  or  easy  fatigue,  and  abnormal  desire 
for  sweets,  or  excessive  thirst,  should  be  investigated. 
Other  subjective  sensations  referable  to  the  vegetative 
nervous  system  or  the  endocrine  glands  may  suggest  them- 
selves. 

16.  DRUG  REACTIONS:  Variations  in  the  reactions  to 
drugs  which  have  a  more  or  less  specific  effect  upon  the 
vegetative  nervous  system  have  been  described  as  indicat- 
ing the  state  of  irritability  of  the  sympathetic  or  autonomic 
portions. 

Pilocarpine,  for  example,  has  been  considered  to  be  a 
stimulator  of  the  autonomic  portion.  It  increases  sweating, 
salivation,  and  other  digestive  fluids,  and  movements  of  the 
intestines.  It  has  been  said  that  when  "a  sub-cutaneous 
injection  of  one  centigram  of  nitrate  of  pilocarpine  pro- 
duces salivation  and  sweating  more  abundant  than 
normal"  (Laignel-Lavastine),  an  increased  irritability 
("vagotonia")  of  the  autonomic  system  is  indicated.  This 
test  may  be  carried  out  by  injecting  1-12  gr.  of  nitrate  or 
hydrochloride  of  pilocarpine,  or  1  c.  c.  of  a  1  per  cent 
solution. 

Atropine  is  looked  upon  a,s  having  a  paralyzing  effect 
upon  the  autonomic  system.  It  dilates  the  pupil,  tends 
to  inhibit  gastro-intestinal  secretions  and  perspiration,  and 
increases  the  heart  rate  by  lessening  the  vagus  inhibition. 
It  is  maintained  that  when  "a  sub-cutaneous  injection  of 
one  milligram  of  neutral  sulphate  of  atropine  produces  a 
rapid  and  prolonged  dilatation  of  the  pupil  with  consider- 
able increase  of  the  pulse  rate,"  an  increased  irritability 
of  the  autonomic  system  is  again  indicated.  This  test  may 
be  carried  out  by  the  injection  of  1-150  gr.  of  atropine 
sulphate  or  1  c.  c.  of  1-1000  solution. 

Adrenalin  is  looked  upon  as  a  stimulator  of  the  sympa- 
thetic system  and  it  has  been  claimed  that  when  "a  sub- 
cutaneous injection  of  one  milligram  of  adrenalin  produces 
glycosuria  in  excess  of  5  grams,  when  the  quantity  of  urine 


52 

is  doubled  and  the  pulse  has  a  rhythm  1-3  above  normal," 
an  increased  irritability  of  the  sympathetic  system 
("sympathicotonia")  is  indicated.  This  test  may  be  car- 
ried out  by  the  injection  of  1  c.  c.  of  a  1-1000  solution  of 
adrenalin.  More  recently  it  has  been  maintained  by  Goetsch 
that  hyper-thyroidism  is  indicated  when  the  injection  of 
.5  cc.  of  a  1-100  adrenalin  solution  is  followed  after  several 
minutes  by  an  appreciable  rise  in  the  systolic  blood  pressure 
and  fall  in  the  diastolic  pressure,  and  an  increase  in  the 
pulse  rate  with  a  gradual  return  to  the  previous  pressure 
and  pulse  rate  after  one  and  a  half  to  two  hours,  and  with 
increase  in  symptoms  of  nervousness  and  tremor.  It  is 
believed  by  him  that  the  increased  thyroid  secretion  in 
such  cases  sensitizes  the  sympathetic  system  so  that  ad- 
renalin injection  promotes  an  excessive  reaction. 

The  significance  of  the  reactions  to  injection  of  these 
drugs  does  not  appear  to  be  as  yet  finally  determined; 
obviously  it  is  difficult  to  standardize  a  normal  reaction. 
It  is  urged,  however,  that  investigation  of  the  reactions  be 
carried  out  to  promote  knowledge  regarding  their  signifi- 
cance in  conjunction  with  the  other  methods  of  examination 
of  the  nervous  system  and  the  endocrines. 

17.  LABORATORY:  Blood  count  with  differential:  Complete 
blood  examination  with  hemoglobin  estimation  and  differ- 
ential count  should  be  carried  out.  It  is  recommended  that 
the  Dare  or  the  Sahli  method  of  hemoglobin  estimation  be 
utilized  rather  than  the  more  simple  Tallquist  method  be- 
cause of  their  greater  reliability.  It  has  been  observed 
that  cases  of  endocrine  disorder  not  infrequently  show  a 
relative  lymphocytosis  with  a  leucopenia.  It  has  also  been 
suggested  by  a  recent  observer  that  the  presence  of  a  rela- 
tive lymphocytosis  indicates  a  developmental  and  physical 
inferiority.  These  claims  need  further  investigation. 

Sugar  Tolerance :  The  power  of  assimilation  of  glucose 
without  the  production  of  a  glycosuria  varies  in  different 
individuals  and  appears  to  be  rather  closely  related  to  en- 


53 

docrine  disease.  The  amount  of  sugar  that  can  be  so  assim- 
ilated is  spoken  of  as  the  sugar  tolerance.  This  has  been 
found  to  be  high  in  such  conditions  as  myxedema,  pituitary 
hypo-function,  adrenal  hypo-function  and  sexual  gland  de- 
ficiency, and  to  be  low  in  hypo-function  of  the  pancreas  and 
in  hyper-function  of  the  thyroid  and  the  pituitary.  The 
average  individual  is  able  to  tolerate  about  200  grams  of 
glucose.  Tests  are  carried  out  by  giving,  therefore,  to  an 
individual  whose  urine  has  been  found  previously  to  con- 
tain no  sugar,  200  gram  of  sugar  with  coffee  or  water  on  a 
fasting  stomach.  The  subsequent  24-hour  urinary  output 
is  examined  for  the  presence  of  sugar ;  preferably,  tests  for 
the  presence  of  sugar  are  made  one,  two,  and  three  hours 
after  the  ingestion  to  determine  the  time  of  appearance 
of  glycosuria  if  present.  Subsequent  tests  with  large  or 
small  amounts  of  glucose  may  be  carried  out  according  as 
200  grams  result  in  the  absence  or  presence  of  glycosuria. 

Blood  Sugar:  The  test  for  the  blood  sugar  content  is 
generally  considered  to  indicate  more  satisfactorily  the 
power  of  assimilation  by  the  body  of  carbohydrates.  The 
test  can  be  carried  out  after  the  manner  of  Benedict-Lewis, 
Folin  or  Einstein,  as  described  in  works  on  physiological 
chemistry  (for  example,  Hawk's  Practical  Physiological 
Chemistry,  1919).  High  blood  sugar  content  in  general  is 
found  in  cases  with  low  sugar  tolerance  and  vice  versa. 

X-Ray:  A  complete  endocrine  and  bodily  development 
examination  should  include  an  X-ray  examination,  partic- 
ularly of  the  head,  so  as  to  determine  the  size  and  shape  of 
the  pituitary  fossa;  evidence  of  calcification  of  the  pineal; 
the  condition  of  the  teeth,  particularly  with  reference  to 
lack  of  development  or  lack  of  eruption;  and  the  condition 
of  the  sinuses,  particularly  with  respect  to  their  size,  as 
indicating  type  of  bony  development.  X-ray  examination 
of  the  epipyses  of  the  extremities,  especially  the  hands, 
brings  out  the  presence  or  absence  of  retarded  bony  de- 
velopment; such  examination  also  demonstrates  bony  over- 
growth. 


54 

18.  ENDOCRINOPATHIES  IN  FAMILY  :    It  is  considered  ad- 
visable to  include  in  the  examination  of  the  patient  whatever 
account  may  be  obtained  from  the  patient  regarding  types 
of  development  in  the  ascendants,  particularly  the  presence 
of  giants  or  dwarfs,  thin  or ! stout  persons,  and  other  evi- 
dence of  endocrine  disease,  such  as  goitre,  diabetes,  and 
sexual  gland  deficiency.    This  does  not  exclude,  of  course, 
inquiry  from  members  of  the  family  regarding  these  con- 
ditions made  'in  the  regular  anamnesis. 

19.  DEVELOPMENTAL  HISTORY  :    Likewise,  it  is  considered 
advisable  to  obtain  from  the  patient,  if  possible,  a  descrip- 
tion of  the  character  and  rate  of  the  personal  development 
with  special  reference  to  rapid  changes  in  weight  or  height. 
Previous  subjective  bodily  sensations  and  sexual  desire  and 
potency  should  be  investigated.    Any  other  information  of 
significance  for  endocrine  disease  obtained  from  the  patient 
should  be  carefully  noted.  • 

20.  SUMMARY:    At  the  end  of  the  examination  a  brief 
descriptive  summary  should  be  made,  indicating  the  type 
of  body  development,  with  enumeration  of  the  signs  and 
symptoms  pointing  to  disturbance  of  one  or  more  endocrine 
glands  or  of  the  vegetative  nervous  system.     An  opinion 
as  to  the  source  or  nature  of  the  abnormal  condition  or  con- 
ditions  found   should   be   expressed   and   indications   for 
treatment,  if  any,  should  be  noted. 


56 


MENTAL  EXAMINATION 

(Synopsis) 
INTRODUCTION 

I .  ATTITUDE  AND  GENERAL  BEHAVIOR 

II.  STREAM  OF  MENTAL  ACTIVITY 

III .  EMOTIONAL  REACTION  :    AFFECT  AND  MOOD 

IV.  MENTAL  TREND:    CONTENT  OF  THOUGHT 

V .  SENSORIUM,  MENTAL  GRASP  AND  CAPACITY 

1.  Orientation 

2.  Data    of    Personal    Identification:    Remote 

Memory 

3.  Memory  of  Recent  Past 

4.  Retention  and  Immediate  Recall 

5.  Counting  and  Calculation 

6.  Reading 

7.  Writing 

8.  Thinking   Capacity,   Attention   and   Mental 

Tension 

9.  School  and  General  Knowledge 

10.  Intelligence  Rating 

11.  Insight  and  Judgment 

VI.     SUMMARY  OF  MENTAL  EXAMINATION 


MENTAL  EXAMINATION 

Introduction  The  first  principle  in  the  observation  of 
mental  disorder  is  to  describe  accurately  and  to  present  the 
facts  so  that  they  can  be  used  in  chains  of  cause  and  effect. 
In  our  descriptions  we  must  get  unequivocal  statements, 
learn  to  avoid  all  terms  which  are  open  to  confusion;  and 
wherever  we  are  in  doubt  about  terms,  we  do  best  to  resort 
to  a  plain  statement  of  events  in  simple,  non-technical 
language.  This  does  not  prevent  our  using  in  our  judgment 
all  the  available  knowledge,  but  it  does  keep  us  from  getting 
involved  in  a  terminology  which  is  often  deceptive  and  tends 
to  make  us  think  that  we  know  more  about  the  case  than 
the  actual  facts  warrant. 

It  is  usually  little  important  that  a  patient  does  or  says 
a  certain  thing ;  but  that  he  does  or  says  it  in  a  definite  set- 
ting, gives  the  act  or  utterance  ithe  value  of  adequacy  or 
inadequacy  of  normal  or  abnormal  working.  Hence  the 
important  rule  in  recording  clinical  observations,  that 
wherever  there  is  anything  peculiar  to  be  demonstrated, 
it  is  necessary  to  give  the  facts  in  their  natural  connections, 
and  very  often  it  is  desirable  to  report  conversations  in 
question  and  answer  form  on  the  ground  that  a  reaction  can 
not  be  judged  without  a  knowledge  of  the  provoking  agent. 

This  does  not  mean  that  the  entire  examination  is  to 
be  reported  in  question  and  answer  form,  a  procedure  very 
rarely  necessary.  Records  are  often  overloaded  with  ques- 
tions and  answers  and  apparently  this  method  is  sometimes 
followed  because  it  seems  the  easiest  way  out,  or  because  of 
inexperience  or  lack  of  appreciation  of  what  a  record 
should  contain.  As  a  rule  the  verbatim  account  should  be 
limited  to  those  questions,  answers,  and  reactions  which 
characterize  a  type  or  serve  the  differential  diagnosis. 

On  the  other  hand,  many  records  are  almost  valueless 
because  they  give  chiefly  the  examiner's  impressions  and 


58 

judgments  without  recording  scarcely  any  of  the  facts  on 
which  the  conclusions  are  based.  It  is  especially  desirable 
to  give  in  the  patient's  own  words  examples  of  the  delu- 
sional ideas  entertained  and  the  hallucinatory  experiences 
if  any  are  described.  (Such  examples  also  may  be  valuable 
in  certain  cases  in  relation  to  medico-legal  questions.)  The 
general  rule  is  that  the  record  should  contain  a  sufficiently 
full  report  of  what  the  patient  actually  said  and  did  to 
permit  the  reader  to  form  an  independent  opinion  of  the 
case  as  a  whole  or  of  the  various  reactions  shown  by  the 
patient. 

One  must  be  prepared  to  spend  much  time  and  effort  in 
acquiring  a  good  technique  of  examination  and  in  learning 
how  to  present  the  facts  with  proper  regard  for  their  psy- 
chiatric worth. 

In  the  direct  examination  of  the  patient  the  mode  of 
approach  is  absolutely  decisive  of  the  result.  The  reserve 
of  the  patient  is  often  very  great,  or  if  not  the  reserve,  at 
least  the  unwillingness  to  show  a  clear  picture  of  peculiar 
experiences.  It  is,  therefore,  necessary  to  gain  the  con- 
fidence by  treating  the  patient  as  a  "sensible  man  or 
woman."  In  most  cases  it  is  positively  essential  to  inter- 
view the  patient  privately;  the  statements  can  then  usually 
be  obtained  quite  freely,  often  with  a  feeling  of  relief  to 
the  patient,  and  a  distinct  gain  in  the  relation  between 
physician  and  patient. 

That  any  chances  for  self-humiliation  must  be  eased  with 
verbal  suggestion  and  that  any  appearance  of  obnoxious 
ridicule  or  dictation  or  correction  and  unnecessary  argu- 
ment must  be  avoided,  should  not  require  special  insistence. 
The  feelings  of  the  patient,  the  general  situation  and  the 
special  idiosyncrasies  (are  to  be  kept  in  mind  before  all. 
The  utmost  care  is  necessary  to  make  the  patient  feel  that 
all  is  done  in  a  spirit  of  helpfulness.  The  establishment  of 
a  comfortable  and  wholesome  relation  of  patient  to 
physicians  and  nurses  should  be  the  keynote  of  all  our 
efforts.  It  is  very  striking  how  much  more  composed  and 


59 

amenable  to  explanations  and  conversation  many  patients 
are  just  on  admission,  than  they  are  only  a  few  hours  or  a 
clay  or  so  later,  especially  if  there  is  any  tendency  towards 
mutism  or  confusion.  One  should,  therefore,  proceed  with 
the  examination  at  the  earliest  possible  moment. 

Physicians  often  make  the  mistake  of  waiting  for  a  dis- 
turbed, delirious  or  negativistic  patient  to  become  quiet 
and  freely  accessible  before  undertaking  the  investigation 
of  the  mental  condition.  It  is,  however,  just  as  necessary 
to  proceed  with  the  examination  of  an  excited,  delirious  or 
stuporous  patient  as  it  is  with  a  quiet  or  cooperative  one. 
The  examination  must  of  course  be  shaped  according  to  the 
condition  of  the  patient,  but  a  good  record  of  the  reactions, 
moods,  utterances,  etc.,  during  the  stormy  or  non-cooper- 
ative period  of  the  psychosis  is  of  the  utmost  importance. 
In  fact,  it  is  just  these  pathological  reactions  that  require 
the  most  painstaking  study  and  description.  It  is,  there- 
fore, inexcusable  to  adopt  the  plan  of  waiting  for  the  dis- 
appearance of  such  symptoms  before  attempting  to  make 
an  examination. 

It  is  very  difficult  to  give  definite  directions  regarding 
the  mental  examination  and  at  the  same  time  avoid  the 
danger  of  producing  records  which  are  merely  formal  de- 
scriptions of  various  more  or  less  detached  aspects  of  the 
case  with  failure  to  show  the  sequence  of  events  and  the 
driving  forces  in  the  development  of  the  abnormal  con- 
dition and  without  which  we  cannot  get  a  clear  picture  of 
the  working  of  the  patient's  mind.  For  purposes  of  order 
and  systematic  approach  it  becomes,  however,  necessary  to 
adopt  some  general  plan  of  work  and  to  arrange  our  ob- 
servations under  certain  topical  headings.  These  are 
selected  because  they  cover  the  most  important  manifesta- 
tions of  mental  disorder  and  have  a  value  in  differential 
diagnosis. 

The  order 'of  arrangement  suggested  in  this  guide  is  not 
necessarily  best  followed  in  every  case.  We  have  to  be 
governed  by  the  condition  of  the  patient  and  the  examin- 


60 

ation,  as  mentioned  above,  must  of  course  be  shaped  ac- 
cording to  the  type  of  disturbance  under  investigation. 
The  experienced  physician  stresses  that  part  of  the  exam- 
ination which  obviously  deals  with  the  most  important 
aspects  of  the  case  before  him. 

It  is  advised  that  in  recording  the  results  of  the  exam- 
ination under  each  division  of  the  guide,  use  be  made 
of  short,  concise  summarizing  headings,  in  capitals,  in 
order  to  indicate  and  emphasize  what  the  important  findings 
are  in  each  one  of  the  various  sub-divisions. 

I.    ATTITUDE  AND  GENERAL  BEHAVIOR : 

We  begin  with  a  brief  description  of  what  the  nurses  and 
we  ourselves  observe  in  the  patient,  a  common  sense  picture 
of  the  patient 's  conduct  and  reaction  to  the  situation.  This 
includes  the  general  demeanor  since  admission,  6r  since 
the  last  note,  with  special  reference  to  the  variations  of 
activity  and  mood. 

The  general  description  should  cover  the  following :  Does 
the  patient  look  sick,  weak  or  strong ;  in  bed  or  up ;  peculiar- 
ities in  dress;  degree  of  self-care  shown;  neat  or  untidy; 
personal  habits^and  cleanliness.  How  does  the  patient  react 
to  the  ward-life  and  routine?  General  mood,  calm,  elated, 
or  depressed.  Adaptable  or  not?  Compliant,  resistive 
or  assaultive?  How  is  the  time  spent,  in  working, 
reading  or  in  idleness?  Sociable  or  seclusive;  how  spon- 
taneous in  conversation,  talks  on  what  topics? 

In  practice  it  is  best  to  write  or  dictate  this  division  of 
the  mental  status  at  the  conclusion  of  the  examination  for 
the  reason  that  the  <: Attitude  and  General  Behavior" 
should  include  a  description  of  what  is  observed  during  the 
interview,  particularly  in  reference  to  the  following: 

General  conduct,  cooperation  and  attention  under  exam- 
atiori ;  manner,  speech  or  posture ;  the  facial  expression  and 
general  appearance  which  may  show  anxiety,  fear,  bewilder- 
ment, perplexity,  exaltation  of  spirits,  irritability,  change- 
ability of  mood,  etc.  Or  there  may  be  displayed  distrust, 


61 

conceit,  ecstasy,  beatitude,  absorption,  etc.,  dilapidated, 
silly  conduct. 

A  close  analysis  of  the  motor  activity  is  extremely  im- 
portant and  will  often  afford  important  points  for  differ- 
ential diagnosis.  In  case  there  is  hyper  activity,  describe 
a  series  of  motions  or  acts,  giving  the  sequence  of  events 
as  faithfully  as  possible.  In  this  way  we  can  recognize 
flights  of  activity,  busy  purposeful  activity,  nervous  rest- 
lessness, stereotyped,  senseless  motions,  automatism, 
aimless  fumbling. 

Examine  resistive  or  non-cooperative  patients  for  neg- 
ativism, muscular  tension,  stiffness,  catalepsy,  suggestibil- 
ity, automatic  obedience,  etc. 

In  states  of  reduced  activity  we  observe  loss  of  initiative 
or  lack  of  spontaneity  or  slowness  in  action.  Make  special 
tests  for  motor  retardation,  e.  g.,  counting,  walking,  dress- 
ing, etc.  Retardation  may  be  initial  or  general. 

In  stupor  we  have  a  complete  lack  of  responsiveness  and 
general  immobility.  A  careful  examination  should  be  made, 
using  the  special  guide  for  non-cooperative  or  stuporous 
patients,  page  81. 

II.     STREAM  OF  MENTAL  ACTIVITY: 

This  is  best  studied  in  the  patient's  spontaneous  account 
of  his  trouble  or,  when  this  is  not  given,  in  the  reactions 
to  special  questions.  This  gives  us  an  idea  of  the  spontan- 
eous productivity  and  of  the  nature  of  the  stream  of 
thought.  Obtain  verbatim  samples  of  the  stream  of  mental 
activity  which  is  always  necessary  if  there  is  any  peculiarity 
in  the  verbal  reactions  or  utterances  of  the  patient. 

The  patient  may  exhibit  no  disorder  in  the  spontaneous 
conversation;  may  answer  questions  promptly,  relevantly 
and  show  logical  progression  in  association  of  ideas. 

The  patient  may  be  over-productive  in  speech  and  show 
volubility,  rambling  talk,  abnormal  divertibility,  flight  of 
ideas,  incoherence,  verbigeration  or  disjointed,  scattered 
utterances.  Or  with  or  without  over-productivity  there 


62 

may  be  distractibility  of  attention,  sound  associations, 
peculiar  expressions,  self-invented  words  or  phrases  (neolo- 
gisms), irrelevancy,  echolalia,  stereotypy,  etc.  It  should 
be  borne  in  mind  that  disturbances  in  the  stream  of  thought 
(flight,  incoherence,  irrelevancy,  etc.)  may  not  appear  at 
once  or  in  response  to  the  first  few  questions.  They  may 
appear  at  some  subsequent  part  of  the  examination  to  which 
reference  should  be  made  so  that  the  reader  can  find  the 
samples.  Often  disturbances  in  the  stream  of  thought  will 
be  brought  out  only  when  the  patient's  delusional  trend  is 
touched  on.  Distractibility  and  flight  in  elaborations  may 
often  be  demonstrated  by  simple  tests,  such  as  showing 
objects,  making  sounds,  speaking  certain  words  and  request- 
ing the  patient  to  give  a  series  of  associations. 

The  patient  may  show  a  diminished  productivity,  give 
few  or  only  an  occasional  utterance,  or  there  may  be  a 
marked  slowness  in  speech  with  evidence  of  retardation  in 
the  mental  processes,  or  the  patient  may  refuse  to  speak  or 
to  answer  any  question — mutism.  In  case  the  patient  seems 
inhibited  or  retarded,  indicate  the  approximate  time  to 
obtain  a  response,  observe  whether  or  not  the  answer  when 
once  started  is  given  rapidly  or  with  slowness,  hesitation 
or  pauses.  (Differentiate  between  an  initial  or  a  general 
consistent  retardation). 

When  the  patient  is  spontaneously  productive,  we  note 
down  at  once  samples  of  the  stream  of  thought  and  then  fol- 
low this  by  a  few  questions  such  as  are  suggested  below. 
The  replies  are  put  down  as  far  as  possible  just  as  they  are 
given,  so  that  it  becomes  possible  to  form  a  picture  of  the 
actual  stream  of  mental  activity  and  attention. 

1.  What  is  your  name? 

2.  What  do  you  do  ? 

3.  Do  you  know  where  you  are  ? 

4.  Do  you  know  why  you  are  here? 

5.  What  trouble  have  you  had? 

These  few  questions  may  already  confront  us  with  a  great  diffi- 
culty in  the  further  examination.  The  patient  may  be  inaccessible, 


63 

as  in  the  states  of  coma,  stupor,  delirium,  excitement,  self-absorp- 
tion, or  indifference,  and  we  must  be  satisfied  with  making  a  good 
description  of  the  attitude  and  general  reactions  and  noting  the 
merely  fragmentary  replies;  or  the  responses  may  show  the  other 
extreme — that  of  profusion  of  activity  or  speech,  and  here  again 
about  the  only  thing  we  may  expect  will  be  fragments  which  how- 
ever, may  be  eminently  characteristic  and  therefore  must  be  faith- 
fully recorded. 

In  these  cases  it  is  particularly  necessary  to  be  familiar  with  the 
special  disease  pictures.  There  is,  however,  a  fair  number  from 
whom  a  more  or  less  satisfactory  spontaneous  account  can  be 
obtained. 

V. 

After  the  situation  is  ascertained  and  an  idea  formed 
as  to  any  disturbance  in  the  stream  of  thought,  the  general 
clearness  and  accessibility,  and  the  patient's  competency 
to  give  an  account  of  the  mental  disorder,  proceed  to  the 
next  topic  for  investigation. 

III.    EMOTIONAL  REACTION :    AFFECT  AND  MOOD: 

Since  abnormalities  of  the  emotions  are  among  the  most 
striking  manifestations  of  mental  disorder,  a  careful 
analysis  of  the  affective  reactions  is  extremely  important. 
The  emotional  state  will,  of  course,  have  to  be  considered 
especially  in  relation  to  the  mental  trend  and  the  general 
activity  of  the  patient,  but  at  some  point  in  the  examination 
it  is  advisable  to  "give  particular  attention  to  the  mood,  and 
to  describe  just  what  deviations  are  observable  in  this 
direction.  In  general  we  may  note  the  objective  and  sub- 
jective aspects  of  the  emotional  reactions :  what  we  see,  the 
facial  expression,  the  attitudes  and  postures,  and  what  the 
patient  tells  us  as  to  his  feelings. 

We  note  whether  the  patient  is  quiescent,  composed, 
complacent,  or  without  any  special  emotional  display. 

Or  irritable,  angry,  happy,  elated,  exalted. 

Or  boastful,  egotistical,  self-satisfied. 

Or  suspicious,  distant,  disdainful. 

Or  depressed,  sad,  hopeless,  anxious,  fearful,  perplexed. 

Or  indifferent,  apathetic,  dull. 


64 

Often  there  is  striking  variability  in  mood,  changeable- 
ness,  etc.,  with  or  without  apparent  external  causes. 

Of  special  importance  is  the  relation  between  affect  and 
thought  content.  We  should  note  carefully  any  inappro- 
priate emotional  reactions  or  discrepancies  between  the 
patient's  ideas  and  the  accompanying  mood.  A  dissociation 
may  be  indicated  by  an  indifferent,  smiling,  or  silly  reaction 
in  the  face  of  ideas  which  would  normally  call  forth  a  de- 
pressive, anxious,  or  distressed  affective  response. 

Even  where  the  patient  is  unresponsive  (or  mute)  we 
may  make  important  observations  as  to  the  affect  by  noting 
the  behavior  of  pulse  and  respiration,  or  the  appearance  of 
flushing,  perspiration,  or  tears,  or  changes  in  facial 
expression,  etc. 

If  the  feelings  are  not  spontaneously  described  by  the 
patient,  appropriate  questions  may  be  asked,  as: 

1.  How  do  you  feel? 

2.  Are  you  happy? 

3.  Are  you  indifferent?     Satisfied? 

4.  Are  you  sad  ?    Troubled  over  something  ? 

5.  Are  you  afraid? 

6.  Are  you  worried? 

In  most  cases  the  examination  will  now  have  furnished  sufficient 
facts  to  recognize  the  general  drift  and  the  nature  of  the  mental 
state,  whether  it  belongs  to  the  delirious,  the  essentially  delusional, 
the  emotional,  or  one  of  the  deteriorating  organic  types.  The 
questionnaire  and  the  amount  of  verbatim  notes  should  be  adapted 
so  as  to  take  in  with  special  care  the  points  of  differentiation — 
positive  and  negative — in  terms  of  simple  tests  wherever  any 
doubt  might  be  foreseen.  It  is  so  easy  to  acquire  a  very  plausible 
vocabulary  that  one  must  over  and  over  insist  on  this  rule. 

IV.  MENTAL  TREND :  CONTENT  OF  THOUGHT: 

We  may  have  already  learned  from  the  preceding  parts 
of  the  examination  a  good  deal  as  to  the  patient's  general 
mental  trend,  whether  or  not  delusional  ideas  or  hallucin- 
ations are  present.  We  desire  now  to  deepen  our  inquiry 
and  to  study  carefully  the  origin  and  elaboration  of  any 


65 

peculiar  ideas,  abnormal  trends,  special  undercurrents,  and 
hallucinatory  experiences. 

The  patient  may  be  willing  and  able  to  give  a  good  ac- 
eount  of  the  beginning  and  subsequent  course  of  the  mental 
disorder.  He  should,  therefore,  have  an  opportunity  to 
tell  his  story  in  full.  In  delusional  states  the  main  emphasis 
will  fall  on  this  part  of  the  status.  The  patient  should  be 
encouraged  to  talk  freely  and  to  recount  in  detail  the  steps 
in  the  development  of  any  suspicious,  morbid  trend  or 
delusional  ideas.  The  aim  should  be  to  get  a  full  report  of 
the  patient's  trend  and  as  far  as  possible  this  should  be 
arranged  in  chronological  order.  In  hospital  or  committed 
eases  the  patient's  account  of  just  what  led  to  admission 
should  be  obtained  and  particular  inquiry  made  as  to  any 
anti-social  acts  or  tendencies. 

If,  as  is  often  the  case,  the  patient  is  reluctant  to  talk 
or  inclined  to  conceal  his  ideas,  we  proceed  with  appro- 
priate questions  along  the  following  lines : 

If  there  are  indications  of  a  persecutory  trend  we  ask 
•oncerning : 

(a)  Sensitiveness  of  being  watched.     (Delusions  of 

reference). 

(b)  Suspicion  of  being  talked  about. 

(c)  Inclination  to  see  a  meaning  in  things. 

(d)  Unpleasant  family  relations,  jealousy,  suspicions 

of  sexual  nature. 

(e)  Suspicions  of  being  wronged,  annoyed,  robbed, 

poisoned. 

(f )  Feelings  of  bodily  influence  by  machines  or  elec- 

tricity, or  mind-reading,  hypnotism,  etc.  How 
is  it  done  and  why?  By  whom?  (See  also 
pseudo-spontaneity  and  passivity).  Blocking  of 
thought?  Interference  with  thinking? 

(g)  Is  there  a  combined  plan  in  all  this? 

(h)     What  makes  you  think  so?     (Systematization, 
retrospective  falsification). 


66 

Hypochondriacal  ideas  or  somatic  delusions  may  be 
brought  out  by  appropriate  questions  as  to  health  and 
strength,  functions  of  the  internal  organs,  bowel  action, 
sexual  power,  condition  of  the  blood,  etc. 

Ideas  of  unreality  may  be  expressed  by  feelings  that  the 
outside  world  has  changed,  that  everything  looks  different, 
or  that  the  individual  has  changed,  that  the  body  is  un- 
natural, feelings  gone,  life  has  ceased,  is  no  longer  a  human 
being,  etc. 

Nihilistic  ideas  may  be  expressed  by  statements  that 
everything  is  lost  or  destroyed,  nothing  exists,  there  is  no 
life,  no  matter,  no  universe,  etc. 

Other  depressive  trends  will  usually  be  indicated  in  the 
paragraph  on  Emotional  Reactions,  although  self-accusa- 
tory ideas  and  feelings  of  guilt  may  be  rather  difficult  to 
bring  out.  Inquiry  should  be  made  regarding  tendency 
to  self-criticism  and  depreciation,  ideas  of  sinfulness  and 
self-condemnation,  of  the  soul  being  lost,  etc. 

Grandiose  ideas  are  more  apt  to  be  freely  expressed  iu 
exalted  emotional  states.  A  few  questions  may  be  put  con- 
cerning ideas  of  strength,  power,  wealth,  high  birth,  etc. 

A  suspicion  of  hallucinatory  experience  leads  to  the 
questions : 

1.  Has  anything  strange  happened? 

2.  Have  you  imaginations'? 

3.  Do  you  have  peculiar  thoughts? 

4.  Do  you  hear  things  ? 

Have  you  heard  any  talking  from  the  neighbors,  or 
people  on  the  street? 

5.  Do  you  see  things  ? 

6.  Have  you  been  disturbed  at  night? 

7.  Do  you  dream  much? 

Frequently  it  is  best  to  make  direct  inquiries  about  more 
or  less  positive  evidence  of  hallucinations  and  delusions  in 
the  behavior  of  the 'patient.  We  may  find  the  patient  listen- 
ing and  mumbling,  or  gesticulating;  or  he  may  suddenly 


67 

turn,  guard  himself,  become  sullen,  or  talk.  The  record 
must,  however,  limit  itself  carefully  to  what  evidence  can 
actually  be  gained.  The  current  term  "  talking  to  imagin- 
ary persons"  is  very  frequently  not  referable  at  all  to  hal- 
lucinations, especially  in  manic  states.  Visions,  fear  of 
poison,  hallucinations  of  smell  and  of  physical  influence 
call  forth  similarly  characteristic  reactions. 

Combined  hallucinations  are  most  frequent  in  episodes 
of  fright  and  terror,  in  dream-states  and  deliria  with 
marked  disorder  of  sensorium. 

Any  such  experiences  of  sense  deceptions,  influence,  etc., 
are  to  be  subjected  to  a  careful  analysis  along  the  following 
lines : 

In  the  case  of  hallucinations  of  hearing : 

1.  Do  you  hear  voices'?        or  noises? 

2.  Where  and  when f    On  what  occasion  ?    In  which  ear? 

(may  be  unilateral) 

3.  Whose  voice? 

4.  Plainly?    Real  voices,  sounds  or  thoughts? 

5.  In  conversation,  to,  or  about  you? 

6.  Do  you  respond?    Do  they  surprise,  affect  and  scare 

you? 

7.  Does  your  tongue  move? 

8.  Can  you  stop  the  talk,  or  can  others?    By  speaking, 

listening  to  other  things?    What  brings  it  on?    Is 
it  worse  at  times? 

In  the  case  of  visual  hallucinations,  inquire  whether  they 
occur  in  plain  daylight,  or  dark,  with  the  eyes  open  or  shut : 
in  any  special  direction :  do  they  move  and  fit  in  with  the 
rest,  seem  natural?  Are  they  transparent  or  not?  Have 
they  color?  Are  they  recognized?  Can  artificial  hallucin- 
ations be  provoked  (pressure  of  the  eye,  gazing  at  a  blank?) 

Are  there  any  hallucinations  of  smell,  taste  or  contact,  or 
organic  sensations  f 

Are  there  illusions  and  misinterpretations? 

Is  there  any  organic  foundation  for  sense  deceptions? 


68 

Do  the  sense  deceptions  of  various  senses  cooperate  (as 
in  dream-states  and  dream-hallucinations  of  the  alcoholic 
and  epileptic  deliria?) 

Do  they  depend  on  special  affects  or  episodes? 

Are  there  any  reflex  hallucinations  (coming  on  merely 
in  certain  circumstances,  such  as  emotion — and  then  uni- 
form?) Any  pseudo-hallucinations  (recognized  as  imagin- 
ations?) 

Hypnagogic  hallucinations  (occurring  just  when  falling 
asleep  or  at  the  moment  of  awakening). 

Has  the  patient  insight  into  the  hallucinations  at  the  time, 
or  afterwards  ? 

In  the  case  of  "peculiar  thoughts": 

1.  Do  you  have  strange  thoughts  ? 

2.  How  do  they  come  to  you? 

3.  What  about? 

4.  Many  kinds,  or  mostly  the  same? 

5.  In  what  relation  to  what  you  think,  or  to  what  others 

say  or  do? 

Pseudo-spontaneity  or  passivity: 

1.  Do  you  do  anything  queer  and  strange  (talk  or  think 

or  act?) 

2.  How  do  you  account  for  it?    Are  there  any  imperative 

thoughts  or  acts?  Pre-occupations ?  Obsessions? 
In  order  to  get  at  the  dynamic  factors  underlying  ab- 
normal emotional  reactions  and  to  trace  out  the  origin  and 
gignificance  of  the  trend,  it  is  usually  necessary  to  have 
repeated  interviews  and  finally  to  make  a  careful  analysis 
of  the  entire  material.  This  further  study  must  often  ex- 
tend over  a  considerable  period  and  the  results  will  natur- 
ally have  to  be  recorded  in  continued  notes  made  subsequent 
to  the  mental  status.  (See  Further  Psychological  Analysis, 
page  78.) 


69 

V.    SENSORIUM,  MENTAL  GRASP  AND  CAPACITY : 

In  all  cases  inquiry  in  this  field  is  essential  in  order  to 
establish  an  estimate  of  the  extent  of  temporary  or  per- 
manent mental  disorganization  of  the  capacities  and 
resources  of  the  individual  and  the  existence  and  origin 
of  any  thinking  disorders.  Neglect  in  this  direction  is  the 
most  common  defect  of  many  records  of  cases  in  whom  an 
error  of  diagnosis  must  subsequently  be  admitted.  Espe- 
cially the  records  of  non-recognized  organic  conditions, 
particularly  paresis,  show  very  often  that  a  thorough 
search  for  gaps  of  memory  and  for  discrepancies  of  chron- 
ological data  has  not  been  made.  In  these  cases  actual 
samples  of  speech  and  writing  are  required  to  establish 
defects.  Moreover,  where  the  patient  has  been  found  un- 
able to  give  a  spontaneous  account,  the  questions  here  pro- 
posed will  very  likely  bring  out  the  most  important  and 
most  valuable  responses  on  which  to  base  diagnostic  con- 
clusions and  comparisons  with  subsequent  conditions  shown 
by  the  patient. 

The  following  questions  indicate  the  lines  along  whick 
inquiries  should  be  pushed.  In  cases  where  something 
definite  is  to  be  demonstrated,  the  question  and  answer 
form  of  recording  results  is  preferable.  In  other  cases  the 
patient's  responses  are  given  as  fully  as  necessary  in  the 
form  of  indirect  discourse. 

1.  ORIENTATION  AS  TO  TIME,  PLACE  AND  PERSON: 

1.  What  place  is  this?    What  house?    What  is  it  fort 

2.  Where  is  it  located?    What  city? 

3.  What  is  the  date?    Year?    Month?    Day  of  month? 

Day  of  week? 

4.  What  time  of  day  is  it? 

5.  Does  the  patient  recognize  the  examiner  as  a  phy- 

sician?   Identify  patients  and  nurses  as  suchf 

2.  DATA  OF  PERSONAL  IDENTIFICATION.  REMOTE  MEMORY : 

The  following  questions  are  aimed  primarily  to  test  the 
grasp  of  the  more  remote  experiences  and  the  ability  to 
correlate  dates  and  give  facts  in  chronological  order.  Some 


70 

physicians  prefer  to  go  further  and  use  these  questions, 
supplemented  by  others,  as  a  basis  for  an  account  by  the 
patient  of  his  life  history,  a  sort  of  anamnesis.  There  is 
no  objection  to  proceeding  in  this  manner  if  it  is  understood 
that  a  regular  anamnesis  from  relatives  or  friends  is  to  be 
obtained  and  recorded  in  the  usual  way  as  soon  as  possible. 
If  the  patient  is  capable  of  giving  reliable  information  the 
physician  may  at  this  point  turn  to  the  statistical  data  sheet 
and  fill  in  as  much  of  the  information  called  for  as  is  deemed 
desirable.  It  is  especially  important  to  do  this  in  patients 
who  have  no  visitors  or  friends,  as  the  information  called 
for  is  needed  for  administrative  purposes,  statistics,  and 
death  certificates. 

1.  Where  were  you  born? 

2.  Date  of  birth? 

3.  How  old  does  that  make  you! 

4.  Where  and  how  long  did  you  go  to  school?    Highest 

grade  completed? 

5.  When  did  you  begin  work?     Name  and  address  of 

first  and  subsequent  employers? 

6.  If  the  patient  is  foreign-born,  ask : 

When  did  you  come  to  the  United  States? 
With  whom?    On  what  ship  and  line? 
How  old  were  you  then? 

7.  Naturalized  citizen  of  the  U.  S.  ?    If  so,  give  date  and 

particulars. 

8.  How  long  in  New  York  State? 

9.  Date  of  marriage?    How  old  were  you  then? 

10.  Names  and  birthdays  of  children? 

11.  Where  were  you  last  employed?    Name  and  address 

of  employer? 

12.  In  what  other  hospitals  treated?    Give  the  dates? 

13.  Family  data:     names  and  birthplaces   of  parents; 

living  or  dead ;  suffered  from  what  pecularities  or 
diseases.  Number  of  children  (brothers  and 
sisters  of  patient),  what  peculiarities  or  diseases 
shown  by  these. 


71 

3.  MEMORY  OF  THE  RECENT  PAST : 

1.  Where   do   you  live?     Street   and   number?     With 

whom? 

2.  How  long  have  you  lived  there? 

3.  When  did  you  leave  home? 

4.  Where  did  you  go,  and  with  whom? 

5.  How  did  you  come  here?    How  did  you  travel  here? 

6.  Who  came  with  you? 

7.  What  was  done  for  you  on  admission? 

8.  How  many  days  here? 

9.  Where  were  you  yesterday?    A  week  ago? 
10.  How  many  meals  have  you  had  today? 

4.  RETENTION  AND  IMMEDIATE  RECALL: 

1.  Give  for  retention  a  street  address  and  a  person's 
name  and  show  a  color,  an  object,  and  the  time  on  the 
watch.    Test  after  5  min.,  1  hour  and  1  day. 

2.  Repeat  immediately  digits  in  series.     (Give  the  first 
and  fourth  series  and  others  if  indicated). 

4-6-9-2  7-3-8-4-6-9-2 

5-3-8-1-7  8-2-9-6-4-7-1-5 

2-9-6-4-8-3  3-5-1-7-4-6-9-2-8 

Record  the  result  of  the  tests  and  show  how  far  the 
patient  can  go  without  mistake.  If  there  is  any  question 
of  a  retention  disorder  additional  tests  can  be  carried  out 
as  follows: 

3.  Execution  of  series  of  orders:    Marie's  three-paper 
test  as  follows : 

Use  3  pieces  of  paper  of  different  sizes  and  give 
different  instructions  for  disposal  of  each,  e.  g.,  throw 
the  largest  piece  out  of  the  window,  put  the  middle- 
size  piece  in  your  pocket  and  give  me  the  smallest 
piece. 


72 

4.  Word  pairs.  Let  the  patient  repeat  the  ten  pairs  and 
then  ask  him  to  give  the  second  word  of  each  pair  when 
the  first  is  repeated  to  him. 

Head  —  hair  Window  —  door 

Room  —  hall  Book  —  pencil 

Chair  —  table  Lake  —  river 

Grass  —  tree  Apple  —  pear 

White  —  red  Pipe  —  tobacco 

5.  COUNTING  AND  CALCULATION  : 

1.  Count  1  to  20  as  rapidly  as  possible. 

2.  Count  backwards  20  to  1. 

3.  Count  coins. 

4.  Simple  calculations: 

4  times  9?  5  and  4?  12  divided  by  6? 

6  times  16?         14  and  9?  63  divided  by  7! 

Begin  with  100  and  subtract  successive  7's. 

5.  Year  and  one-half  interest  on  $200  at  4  per  cent. 

6.  If  5  times  X  equals  20,  how  much  is  X? 

In  all  the  tests  give  the  time  required  in  seconds  or 
minutes,  so  that  comparisons  can  be  made  later.  Also  de- 
scribe the  effort  made  by  the  patient  to  cooperate,  and  if 
there  are  delays,  slowness  or  errors,  how  does  the  patient 
explain  them?  Any  feeling  of  mental  insufficiency? 

6.  READING : 

A  short  story  or  paragraph  with  subsequent  rendering 
of  the  contents :  Can  the  patient  get  the  point  of  a  story, 
grasp  the  sense  and  retain  the  detail?  Or  does  he  show 
flight  in  elaborations,  etc.?  For  routine  test  the  "Cowboy 
Story"  is  suggested.  The  patient  reads  the  story  and  is 
then  asked  immediately  to  tell  what  it  was  about. 

A  cowboy  from  Arizona  went  to  San  Francisco  with  his  dog 
which  he  left  at  a  friend's  while  he  purchased  a  new  suit  of  clothes. 
Dressed  finely,  he  went  back  to  the  dog,  whistled  to  him,  called  hiui 
by  name,  and  patted  him.  But  the  dog  would  have  nothing  to  da 


73 

with  him  in  his  new  hat  and  coat  but  gave  a  mournful  howl. 
Coaxing  was  of  no  effect  so  the  cowboy  went  away  and  donned  his 
old  garments,  whereon  the  dog  immediately  showed  his  wild  joy 
on  seeing  his  master  as  he  thought  he  ought  to  be. 

7.  WRITING : 

Name,  address  and  date,  also  some  dictated  sentence,  suck 
as:  "This  is  a  beautiful  September  day." 

Slow,  constrained  or  free! 

Show  omissions  or  transpositions  of  letters  or  syllables  T 
(Important  in  suspected  paresis.) 

Mannerisms  ? 

8.  THINKING  CAPACITY,  ATTENTION  AND  MENTAL  TENSION  : 

The  foregoing  tests  will  usually  furnish  data  on  whick 
to  base  an  estimate  of  the  patient's  ability  to  think,  con- 
centrate, fix  the  attention  and  to  correlate  dates  and  facts 
of  experience.  Evidences  of  temporary  interference  with 
capacities,  with  activization  of  memories  and  with  mental 
tension  should  be  noted,  with  examples. 

Some  additional  tests  may  be  given  for  attention  and 
capacity  of  grasp,  as  follows: 

1.  Lines  of  digits  or  letters  are  read  aloud  to  the  patient  who 
is  required  to  tap  each  time  a  certain  digit  or  letter  occurs.     Or 
the  lists  may  be  given  to  the  patient  with  the  instruction  to  cross 
out  the  designated  digits  or  letters.     (See  Franz:    Mental  Exam- 
ination Methods,  page  71.) 

Any  printed  page  may  be  used  and  the  patient  instructed 
to  cross  out  the  specified  letter.  (Number  or  letter  checking  tests.) 

2.  Heilbronner  test :    Outlines  of  various  familiar  objects  drawn 
with  varying  degrees  of  completeness  are  shown  for  recognition. 
(Franz,  p.  80.) 

9.  SCHOOL  AND  GENERAL  KNOWLEDGE  : 

In  some  cases  it  is  desirable  to  investigate  the  ability  to 
reproduce  what  was  learned  at  school  and  also  to  test  the 
range  of  the  patient's  general  information  and  grasp  of 
current  events.  The  tests,  of  course,  should  be  made  with 
due  regard  to  nationality,  educational  level,  and  general 


74 

experiences  of  the  individual.  Tests  already  made  under 
Counting  and  Calculation,  Reading,  Writing  and  Thinking 
Capacity,  will  have  given  a  good  deal  of  information  as  to 
school  knowledge  and  mental  level. 

If  there  is  any  evidence  that  the  patient  is  illiterate, 
mentally  deficient,  or  markedly  deteriorated,  the  following 
simple  questions  may  be  given : 

1.  What  grade  did  you  reach  at  school? 

2.  Repeat  the  alphabet?     (In  English  or  native  lan- 
uage). 

3.  Give  the  days  of  the  week  ?    The  months  f 

4.  How  do  you  spell  chair?     bridge?     hospital?     con- 
ductor? 

If  there  are  no  indications  for  giving  the  above  tests,  the 
examiner  may  proceed  at  once  with  the  following  historical 
or  geographical  questions  which  should  be  readily  answered 
by  anyone  who  has  passed  through  the  grammar  school  in 
this  country  :* 

1.  When  and  by  whom  was  the  Declaration  of  Independ- 
ence made?    (July  4,  1776,  the  Continental  Congress  of  the 
13  original  colonies.) 

2.  When   was   the   Civil   War?     What   was   it   about? 
(1861-5,  the  right  of  secession  and  abolition  of  slavery.) 

3.  Name  the  oceans. 

4.  Five  largest  cities  in  U.  S.     (or  the  patients  native 
country.) 

5.  Where   is   Brussels?     Rome?     Havana?     Moscow! 
Pekin? 

6.  What  is  the  Gulf  Stream? 

The  following  may  be  used  as  tests  for  general  knowledge 
and  grasp  of  current  events:  (Questions  No.  4  and  No.  5, 

*  For  persons  educated  in  foreign  countries  the  first  two  questions  should 
be  replaced  by  equivalent  questions  relating  to  the  history  of  the  native 
country.  All  of  the  other  questions  in  this  section  are  suitable  for  foreigners 
who  have  had  the  equivalent  of  a  grammar  school  education. 


75 

may  not  be  considered  suitable  for  foreigners  unless  they 
understand  English  and  came  to  the  U.  S.  prior  to  1917.) 

1.  Who  invented  the  steam  engine?    The  phonograph! 
Wireless  telegraphy? 

2.  Can  you  explain  what  causes  the  seasons'?     Why  is 
it  warm  in  summer  and  cold  in  winter  ? 

3.  What  was  the  immediate  cause  of  the  world  war  I 
Tell  what  nations  fought  on  each  side? 

4.  What  were  the  last  two  amendments  to  the  Consti- 
tution of  the  U.  S.? 

5.  What  do  you  understand  by  the  phrase  "Make  the 
world  safe  for  Democracy"?    Who  first  used  it? 

10.     INTELLIGENCE  RATING: 

The  intellectual  level  of  the  patient  may  be  judged  to  a 
considerable  extent  by  the  results  of  the  preceding  parts 
of  the  examination.  If  there  is  reason  to  suspect  that  the 
individual  is  sub-normal  in  intelligence,  a  psychometric  de- 
termination is  indicated.  This  of  course  cannot  be  done 
satisfactorily  unless  the  patient  is  accessible  and  coopera- 
tive. 

Great  care  must  be  exercised  in  judging  the  results  of 
a  psychometric  test  in  the  presence  of  a  psychosis.  In  some 
psychotic  states,  because  of  the  abnormal  emotional  re- 
actions, lack  of' effort,  inattention,  inhibition,  negativism, 
delusional  ideas,  etc.,  a  mental  age  rating  would  be  quite 
misleading  or  worthless. 

In  cases  suitable  for  testing  it  is  recommended  that  use 
be  made  of  the  Stanford  revision  of  the  Binet-Simon  scale 
(a  modified  form  for  which  is  supplied  by  Utica  State 
Hospitals  Press)  and  of  Healy's  performance  or  construc- 
tion tests. 

A  good  plan  is  always  to  give  a  few  intelligence  tests  as 
a  routine  during  the  mental  status.  These  will  yield  con- 
siderable information  as  to  the  intellectual  abilities  and 
help  in  determining  whether  additional  special  tests  are 
advisable  or  not.  For  this  purpose  any  or  all  of  the  fol- 


76 

lowing  tests,  which  can  be  fairly  rapidly  given,  are  sug- 
gested :* 

1.  Healy's  Construction  Test   A. 

This  is  carried  out  by  means  of  a  small  standard 
form  board  and  is  a  9  or  10-year  level  test. 

2.  Healy's  Construction  Test  B. 

Requires  another  type  of  form  board  and  is  a  11 
or  12-year  level  test. 

3.  Differences  betiveen  a  president  and  a  king. 

This  is  a  14-year  level  test  in  the  Stanford  Binet- 
Simon  scale.  ' '  There  are  three  main  differences 
between  a  president  and  a  king,  what  are  they? 
(Accession,  tenure,  power.) 

4.  Reversing  hands  of  a  clock. 

This  is  a  14-year  level  test.  ''Suppose  it  is  22 
minutes  past  6  on  the  clock ;  can  you  see  in  your 
mind  where  the  hands  are?  Suppose  the  hands 
are  shifted — the  long  hand  turned  to  the  place 
of  the  short  hand  and  the  short  hand  to  the  place 
of  the  long  hand.  What  time  would  it  then  be 
on  the  clock? 

If  a  second  trial  is  given  use  10  minutes  past 
8  o'clock. 

5.  Interpretation  of  fables. 

An  average  adult  test  in  the  Stanford  Binet-Simon 
scale.  The  fable,  "The  Fox  and  the  Crow," 
is  read  aloud  to  the  patient  and  the  question 
then  asked:  What  lesson  does  that  teach? 

' '  A  crow,  having  stolen  a  bit  of  meat,  perched  in  a  tree  and  held 
it  in  her  beak.  A  fox,  seeing  her,  wished  to  secure  the  meat,  and 
spoke  to  the  crow  thus :  ' '  How  handsome  you  are !  and  I  have  heard 
that  the  beauty  of  your  voice  is  equal  to  that  of  your  form  and 
feathers.  Will  you  not  sing  for  me,  so  that  I  may  judge  whether 

*  The  physician  should  be  thoroughly  familiar  with  the  approved  methods 
of  giving  these  tests,  the  scoring  and  the  interpretation  of  the  results.  For 
description  and  directions  see:  Healy  and  Fernald,  Psychological  Mono- 
graphs, Vol.  13,  No.  2,  March,  1911;  Healy,  The  Individual  Delinquent,  p. 
830;  Terman,  The  Measurement  of  Intelligence. 


77 

this  is  true?"  The  crow  was  so  pleased  that  she  opened  her 
mouth  to  sing  and  dropped  the  meat,  which  the  fox  immediately 
ate." 

After  the  patient  has  answered  the  question:  what 
lesson  does  that  teach :  Then  the  examiner  should 
ask:  Have  you  heard  that  before? 

6.  Differences  between  abstract  words. 

An  average  adult  test.     What  is  the  difference 

between : 

Idleness  and  Laziness? 
Poverty  and  Misery? 
Character  and  Reputation? 

7.  Repeat  six  digits  backwards. 

An  average  adult  test.    The  following  two  series 
may  be  used:    4-7-1-9-5-2;  5-8-3-2-9-4. 

11.    INSIGHT  AND  JUDGEMENT: 

The  questions  here  concern  the  patient's  judgment  of  the 
situation,  appreciation  of  the  physical  and  mental  condi- 
tions, need  for  treatment,  etc. 

Does  the  patient  realize  that  he  has  suffered  a  mental 
change  or  breakdown?  Acknowledge  that  he  has  had  wrong 
ideas  or  imaginations  ? 

Is  the  patient  sensitive  to  errors  made,  appreciate  defects 
of  memory  or  other  failure  of  capacity? 

What  are  the  plans  in  case  of  discharge  ? 

VI.  SUMMARY  OF  THE  RESULTS  OF  THE  MENTAL  EXAMI- 
NATION: 

A  concise  summary  of  the  main  findings  established  dur- 
ing the  mental  examination  should  now  be  made.  The 
positive  features  should  be  emphasized  with  special  regard 
to  symptom-complexes  and  diagnostic  considerations.  In 
functional  cases  an  attempt  should  be  made  to  specify  as 
far  as  possible  the  psychogenic  factors  and  mental  mechan- 
isms involved  in  the  evolution  of  the  disorder. 


FURTHER  PSYCHOLOGICAL  ANALYSIS 

As  mentioned  on  page  68  an  understanding  of  the  dy- 
namic forces  underlying  the  emotional  and  trend  reactions 
and  the  psychogenic  mechanisms  at  work  in  a  given  case 
requires  a  number  of  interviews  and  a  careful  sifting  of  all 
the  data  available.  In  addition  to  what  is  established  by 
the  anamnesis  and  study  of  the  make-up,  and  by  the  an- 
alysis of  the  mood  and  mental  content  as  outlined  in  the 
mental  status,  an  effort  should  be  made  to  investigate  as 
thoroughly  as  possible  the  conscious  and  unconscious 
wishes  and  conflicts  of  the  patient  and  their  relation  to  the 
development  of  the  psychosis. 

This  should  include  a  painstaking  study  of  the  earliest 
affective  experiences  and  their  influence  on  later  develop- 
ments; investigation  of  any  persistent  infantile  interests 
or  unusual  attachments;  a  careful  probing  for  submerged 
or  dissociated  complexes,  and  for  repressed  instinctive 
desires  or  individualistic  tendencies  which  stand  in  conflict 
with  the  main  or  socialized  personality — any  or  all  of  which 
may  prove  to  be  factors  of  dynamic  importance  in  the  de- 
velopment of  psychoneurotic  or  psychotic  manifestations. 
Material  that  is  definitely  beyond  the  range  of  conscious 
memories  may  be  disclosed  in  suitable  cases  by  the  one  or 
other  of  the  following  methods : 

1.  Free  association:  With  relaxation  of  attention  and 
without  inhibition  the  patient  is  encouraged  to  give  consecu- 
tive associations  of  ideas  just  as  they  come  into  conscious- 
ness without  any  regard  to  sense,  logic  or  chronological 
order.  In  this  way  we  may  ask  the  patient  to  associate  to 
any  aspect  of  the  trend  or  any  idea  which  is  prominent  in 
the  psychosis. 

Much  may  be  learned  of  unconscious  trends  from  a  study 
of  the  utterances  of  excited  or  incoherent  patients  where 
the  inhibitions  are  to  a  large  extent  removed  and  free  asso- 


79 

elation  has  sway.  In  such  cases  one  should,  therefore, 
make  a  record  of  the  productions,  stenographic  if  possible, 
in  order  to  get  good  samples  of  the  type  of  associations 
and  of  whatever  topics  or  dominant  trends  appear  in  the 
psychosis.  These  productions  should  be  gone  over  with 
the  patient  when  more  accessible  or  when  convalescent.  A 
great  deal  that  comes  out  in  the  psychosis  may,  of  course, 
subsequently  be  partially  or  completely  repressed. 

2.  Hypnosis:     The  more  pronounced  mental  cases  are 
rarely  suitable  subjects  for  hypnosis,  but  the  psychoneu- 
roses  and  milder  psychoses  may  often  be  investigated  by 
this  method.    The  object  is  to  get  at  subconscious  mental 
trends  or  conflicts  of  which  the  person  is  not  aware  in  ordin- 
ary states  of  consciousness.     Hypnosis  is  especially  val- 
uable as  a  means  of  clearing  up  psychogenic  amnesias  by 
re-attaching  dissociated  memories  to  consciousness. 

3.  Dream  analysis:    As  the  dream  content,  in  adults  at 
least,  is  drawn  largely  from  the  unconscious,  it  affords 
material  for  study  of  the  unconscious  mental  life.    Dream 
analysis  may,  therefore,  supplement  in  an  important  way 
the  study  of  psychotic  trends  and  other  abnormal  mental 
reactions. 

The  technique  of  psychological  analysis  and  detailed 
directions  for  case  study  cannot  be  gone  into  here.  The 
physician  should  become  as  soon  as  possible  thoroughly 
familiar  with  the  literature  on  this  subject.  The  following 
books  and  articles  are  especially  recommended:  " Mental 
Mechanisms"  by  White;  "A  General  Introduction  to  Psy- 
choanalysis," by  Freud;  "Technique  of  Psychoanalysis," 
by  Jelliff e ; ' '  Psychogenic  Factors  in  the  Psychoses, ' '  Hoch, 
Psychological  Bulletin,  Vol.  4;  "A  Study  of  Benign  Psy- 
choses," Hoch,  Johns  Hopkins  Bulletin,  Vol.  26;  "Mental 
Mechanisms  in  Dementia  Prascox,"  Hoch,  Journal  Abnor- 
mal Psychology,  Dec.,  1910. 


80 


EXAMINATION  OF  NON-COOPERATIVE  OR 
STUPOROUS  PATIENTS 

(Synopsis) 

I.     GENERAL,  REACTION  AND  POSTURE 
II.     FACIAL,  MOVEMENTS  AND  EXPRESSION 

III.  EYES  AND  PUPILS 

IV .  REACTION  TO  WHAT  is  SAID  OR  DONE 
V.     MUSCULAR  REACTIONS 

VI.  EMOTIONAL  RESPONSIVENESS 

VII .  SPEECH 

VIII .  WRITING 

IX.  SOMATIC  REACTIONS 


EXAMINATION  OF  NON-COOPERATIVE  OR 
STUPOROUS  PATIENTS 

The  difficulty  of  getting  information  from  non-coopera- 
tive patients  should  not  discourage  the  physician  from 
making  and  recording  certain  observations.  These  may  be 
of  great  importance  in  the  study  of  various  types  of  cases 
and  give  valuable  data  for  the  interpretation  of  different 
clinical  reactions.  It  is  hardly  necessary  to  say  that  the 
time  to  study  negativistic  reactions  is  during  the  period  of 
negativism,  the  time  to  study  a  stupor  is  during  the  stupor- 
ous  phase.  To  wait  for  the  clinical  picture  to  change  or 
for  the  patient  to  become  more  accessible  is  often  to  miss 
an  opportunity  and  leave  a  serious  gap  in  the  clinical 
observation.  Obviously  it  is  necessary  in  the  examination 
of  such  cases  to  adopt  some  other  plan  than  that  used  in 
making  the  usual  mental  status.  The  following  guide  was 
devised  to  cover  in  a  systematic  way  the  most  important 
points  for  purposes  of  clinical  differentiation. 

I.     GENERAL  REACTION  AND  POSTURE : 

(a)  Attitude  voluntary  or  passive. 

(b)  Voluntary    postures    comfortable,    natural,    con- 

strained or  awkward. 

(c)  What  does  the  patient  do  if  placed  in  awkward  or 

uncomfortable  positions. 

(d)  Behavior  toward  physicians  and  nurses:  resistive, 

evasive,  irritable,  apathetic,  compliant. 

(e)  Spontaneous  acts:  any  occasional  show  of  playful- 

ness, mischievousness  or  assaultiveness.  Defense 
movements  when  interfered  with  or  when  pricked 
with  pin.  Eating  and  dressing.  Attention  to 
bowels  and  bladder.  Do  the  movements  show  only 
initial  retardation  or  consistent  slowness  through- 
out! 


82 

(f)  To  what  extent  does  the  attitude  change?  Is  the 
behavior  constant  or  variable  from  day  to  day! 
Do  any  special  occurrences  influence  the  con- 
dition? 

H.     FACIAL  EXPRESSION: 

Alert,  attentive,  placid,  vacant,  stolid,  sulky,  scowling, 

averse,  perplexed,  distressed. 
Any  play  of  facial  expression  or  signs  of  emotion :    tears, 

smiles,  flushing,  perspiration.    On  what  occasions? 

III.  EYES : 

Open  or  closed.    If  closed,  resist  having  lid  raised. 
Movements  of  eyes :    absent  or  obtained  on  request ;  give 

attention  and  follow  the  examiner  or  moving  objects; 

or  show  only  fixed  gazing,  furtive  glances  or  evasion. 

Rolling  of  eyeballs  upward. 
Size  and  play  of  pupils  (hippus?) 
Blinking,  flickering,  or  tremor  of  lids. 
Reaction  to  sudden  approach  or  threat  to  stick  pin  in 

eye. 
Sensory   reaction   of    pupils    (dilatation    from    painful 

stimuli  or  irritation  skin  of  neck). 
Corneal    irritability    (with    or    without    appearance    of 

tears.) 

I V.  REACTION  TO  WHAT  IS  SAID  OR  DONE : 

Commands :    show  tongue,  move  limbs,  grasp  with  hand 

(clinging,  clutching,  etc.) 
Motions  slow  or  sudden. 
Reaction  to  pin  pricks. 
Automatic  obedience:    Tell  the  patient  to  protrude  the 

tongue  to  have  pin  stuck  into  it. 
Echopraxia:    imitation  of  actions  of  others. 

V.  MUSCULAR  REACTIONS : 

Test  for  rigidity:    muscles  relaxed  or  tense  when  limbs 
or  body  is  moved.    Catalepsy,  cerea  flexibilities.    Nega- 


tivisni  shown  by  movements  in  opposite  direction  or 
springy  or  cog-wheel  resistance. 

Test  head  and  neck  by  movements  forward  and  back- 
ward and  to  side.  Test  also  the  jaw,  shoulders,  elbow, 
fingers  and  the  lower  extremities. 

Does  distraction  or  command  influence  the  reactions? 

Closing  of  mouth,  protrusion  of  lips  (schnauzkrampf). 

Holding  of  saliva,  drooling. 

Sphincters :  retention  of  urine  and  bowels,  soiling  and 
wetting. 

VI.  EMOTIONAL  RESPONSIVENESS: 

Is  feeling  shown  when  talked  to  of  family  or  children! 

Or  when  sensitive  points  in  history  are  mentioned  or 

when  visitors  come? 
Note  whether  or  not  acceleration  of  respiration  or  pulse 

occurs;  also  look  for  flushing,  perspiration,  tears  in 

eyes,  etc. 

Do  jokes  elicit  any  response! 
Effect  of  unexpected  stimuli  (clap  hands,  flash  of  electric 

light). 

VII.  SPEECH: 

Any  apparent  effort  to  talk,  lip  movements,  whispers, 
movements,  of  head. 

Note  exact  utterances  with  accompanying  emotional  re- 
action (may  indicate  hallucinations). 

VIII.  WRITING : 

Offer  paper  and  pencil.  Irresponsive  or  partially  stupor- 
ous  patients  will  often  write  when  they  fail  to  talk. 

IX.  SOMATIC  REACTIONS: 

(a)  Temperature,  pulse,  respiration. 

(b)  Blood  pressure. 

(c)  Vasomotor  reactions:  skin  warm,  cool  or  greasy; 

cyanosis,  flushing,  dermatographia. 

(d)  Skin  reflexes. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 

MAY  a  3  1956  ^LIBRARY  LOANS LSRMLS 


2  I 
2  1 


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"APR  181981$ 


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OCT  8  0  1963 


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DEC  17 


Form  L9-10m-9,'54(7413s4)444 


3  1158  00497  3045 


A     000355466 


